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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ACIIfY I SERVICE REQUEST # <br /> Cardlock <br /> OWNER / OPERATOR / p Z01 , CHECK if BILLING ADDRII <br /> r� f <br /> Carlos Coria <br /> FACILITY NAMEt <br /> Van De PolNr�1 I j )A � � <br /> SITEADDRESS 95366 <br /> E . Frontage Rd : � I ? rj Ripon <br /> Cit Zip Code <br /> 816 Street Number Direction Street Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 1107 Street Number Street Name <br /> STATE Zip <br /> CITY CA, 95201 <br /> Stockton1 11 1 11 <br /> I 1 1111 1111111 111 LAND USE APPLICATION # <br /> PHONE #1 ExT APN # <br /> ( 209 ) 242-5248 <br /> PHONE #E Exr. I DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br />€ <br /> CHECK if BILLING ADDRESS <br /> REQUESTOR <br /> Donlee Pump CompanyPHONE # ExT. <br /> BUSINESS NAME 209 537-9396 <br /> FAX # <br /> HOME or MAILING ADDRESS <br /> 2825 Railroad Ave . ( los ) 537-9 <br /> STATE Zip <br /> CITY Ceres , CA. 95307 <br /> BILLING ACKNOWLEDGEMENT: I , 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 or <br /> activity will be billed to me or my business as identified on this form . <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 /> APPLICANT' S SIGNATURE : DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 1Z Admin . <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign Is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property located at the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time it Is provided to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : <br /> ACCEPTED BY : <br /> EMPLOYEE #: DATE: <br /> ASSIGNED TO : <br /> EMPLOYEE # : DATE: <br /> Date Service Completed (if already completed) : <br /> SERVICE CODE: PIE : <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice # Check # Received By : <br /> SR FORM (Golden Rod) <br /> EHD 48-1 <br /> 07/17/08 <br />