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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST SERVICE REQUEST # <br /> � <br /> Type of Business or Property FACILITY ID # 0�039 <br /> � ' `�j/ <br /> Cardlock CHECK if BILLING SSL�LJ <br /> OWNER / OPERATOR <br /> Carlos Coria <br /> FACILITY NAME 95366 <br /> Van De Pol Ripon <br /> Cit zi Code <br /> SITEADDRESS <br /> E. Frontage Rd . Street Name <br /> 816 street Number Direction <br /> HOME or MAILING ADDRESS (If Different from Site Address) street Name <br /> Street Number ZIP <br /> PO Box 1107 STATE 95201 <br /> CITY CA . <br /> Stockton LAND USE APPLICATION # <br /> EXT. APN # <br /> PHONE #1 <br /> ( 209 ) 242-5248 BOS DISTRICT LOCATION CODE <br /> EXT. <br /> PHONE #2 <br /> ( ) <br /> CONTRACT <br /> TSERVICE nEENCSll ® LL <br /> CHECK if BILLING EA <br /> REQUESTOR ExT. <br /> Donlee Pum Com an PHONE # <br /> 209 537-9396 <br /> BUSINESS NAME <br /> FAx # <br /> HOME or MAILING ADDRESS ( 209 ) 537-9398 <br /> 2825 Railroad Ave . STATE ZIP <br /> CITY Ceres , CA. 95307 <br /> BILLING ACKNOWLEDGEMENT: I , the undersigned property or business owner, operator or authorized agent of same , <br /> t specific Efied on tis sTAL HEALTH DEPARTMENT <br /> acknowledge that all site and/or projec <br /> hourly charges associated with this project or <br /> activity will be billed to me or my business as Iden <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes ) Standards, STATE and FEDERAL laws . , <br /> DATE : <br /> APPLICANT ' S SIGNATURE : <br /> OPERATORIMA A ER ❑ OTHER AUTHORIZED AGENT ® Admin . Title <br /> PROPERTY I BUSINESS OWNER ❑ located at the above <br /> If APPLICANT IS not the BILLING P?RTY, Proof of applicable , la the owneroroperator of the property <br /> AUTHORIZATION TO RELEASE IN When app ' <br /> DEPARTMENT as soon as it is available anhe same time it is provided to me or <br /> site address , hereby authorize the release of any and all results , geotechnical data and/ore nmentallsti assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH j <br /> my representative . <br /> t - <br /> TYPE OF SERVICE REQUESTED : -TAL HEAET " <br /> COMMENTS: ENVIFt0NMEN <br /> nEPARTM'E�`1T <br /> d <br /> DATE: <br /> � � ---�� ---� EMPLOYEE #: q ,r�� <br /> i� ( ' <br /> ACCEPTED BY : ��/ ' ' tY� EMPLOYEE #: l DATE: <br /> ASSIGNED TO : rx `� v SERVICE CODE q (Y� PIE: <br /> Date Service Completed ( if already completed) : � / x/ <br /> / <br /> Amount PaiO_ q56 , YD Payment Date <br /> Fee Amount: Received By : <br /> Payment Type <br /> Invoice # Check # 3 7001 <br /> SR FORM (Golden Rod) <br /> EHD 48-02-025 <br /> 07117108 <br />