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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />I <br />PHONE# Err' <br />916 916-371-2380 <br />HOME or MAILING ADDRESS <br />OWNER/ OPERATOR <br />FAx # <br />CHECK if BILLING ADDRESS❑ <br />kelli kishida <br />( ) <br />CITY West Sacramento <br />FACILITY NAME <br />SERVICE CODE: at <br />George Kishida Inc. <br />Fee Amount: <br />Amount Pa <br />`JC 1 , D a <br />Payment Date <br />S �g <br />Payment Type <br />Invoice# <br />SITE ADDRESS <br />Received By: <br />1725 Street Number <br />I Dlreeticn Ackerman Dr %e <br />NaM, <br />Lodi <br />cint957 <br />HOME Or MAILING ADDRESS (if Different from Site Address) <br />S[reet Numterstreet <br />Name <br />CITY <br />STATE <br />ZP <br />PHONE #1 Err. <br />APN # <br />LAND USE APPUCA71ON # <br />( 209) 368-0603 <br />PHONE92 Err. <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS® <br />BUSINESS NAME <br />B2 Service Station Maintenance <br />ACCEPTEo BY: A 1 a r.-Mcunv <br />�l <br />PHONE# Err' <br />916 916-371-2380 <br />HOME or MAILING ADDRESS <br />DATE: <br />FAx # <br />PO Box 933, <br />EMPLOYEE #: <br />no cq <br />( ) <br />CITY West Sacramento <br />STATE Ca ZIP 95691 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />1 also certify that I have prepared this application and that the wort: to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards. STATE and FE RAL laws. <br />APPLICANT'S SIGNATURE: YI-Rll L' D;,LTE: 1WWI 7 <br />PROPERTY/BCsixESS OWNER❑ OPERATORI NIANAGER 13 OTHER ACTIIORIZEDAGENT ❑ <br />If APPLICA T is not the BILLIA'G PART) ,proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located � "IV" E <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or envi si <br />information t0 the SAN JOAQUINCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Q.- + <br />COMMENTS: <br />JAN 0 5 <br />ENVIRONMEN <br />DEPART <br />ACCEPTEo BY: A 1 a r.-Mcunv <br />�l <br />EMPLOYEE #: �,lt�L1 <br />171J <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />no cq <br />DATE: f <br />Date Service Completed (if already completed): <br />Ll <br />SERVICE CODE: at <br />PIE: <br />O <br />Fee Amount: <br />Amount Pa <br />`JC 1 , D a <br />Payment Date <br />S �g <br />Payment Type <br />Invoice# <br />Ch # 6 d <br />Received By: <br />EHD 48-02-025 <br />REVISED 11!17!2003 SR FORM (Golden Rod) <br />2013 <br />AL Hf <br />GENT <br />