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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY <br />ID # <br />PHONE# Exr. <br />224-7280 <br />(916) woffiffiffisk <br />SERVICE REQUEST # <br />ST <br />CITY Rancho Cordova STATE CA ZIP 95742 <br />*(A OW <br />�5 <br />COMMENTS: <br />S906 110'* <br />OWNER /OPERATOR <br />V <br />• <br />Pacific Gas & Electric <br />CHECK if BILLING ADDRESS <br />FACILITY NAME Pacific Gas & Electric, Stockton Service Center <br />SITE ADDRESS <br />040 <br />West bane <br />Stockton <br />Now <br />95204 <br />lreet14umber <br />DinnUon <br />Street Name <br />City <br />Zip Code <br />HOME or MAILINo ADDRESS (If Different from Site Address) <br />Street Number <br />UIN COU <br />� 4L7y N SNr <br />Street Na e <br />CITY <br />STATE <br />Zip <br />PHONE#t Exr. <br />APN # <br />LAND USE <br />APPLICATION # <br />1 . <br />✓ ��. <br />I ` 4 <br />IW41 YEE #: %- <br />( ) <br />�� / Mtr <br />ASSIGNED TO: <br />G1 <br />PHONE#2 Exr• <br />BOS DISTRICT <br />j <br />LOCATION CODE <br />. <br />DATE: <br />P'.!2 <br />Date Service Completed <br />CONTRACTOR /SERVICE REQUEST®R <br />R>=QUESTOR Kristin Reynolds " ,� . CHECK if BILLING ADDRESS® <br />BUSINESS NAME T.A.IT Environmental Services <br />PHONE# Exr. <br />224-7280 <br />(916) woffiffiffisk <br />HOME or MAILING ADDRESS 11280 Trade Center Drive <br />FAX# <br />( ) <br />CITY Rancho Cordova STATE CA ZIP 95742 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all slte an project specific ENVIRONMENTAL HEALTH DEPARTMt=NT hourly charges associated with this project or <br />activity will be billed to me or my business as Identified on this form. <br />also certify that !have prepared this application and that the work to be performed will be <br />done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, S and FEDERAL laws. <br />APPLICANT'S SIGNATURE: V��bAre: ffj 111I <br />t <br />PROPERTY I BUSINESS OWNER Q OPERATOR /MANAGER © OTHER AUTHORIZED AGENT MContractor <br />If APPLicANT is not the 9&L/NG 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 />Ate address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment Information <br />t0 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. Raw mils anti remove existfn>r waste oil shill bucket / Install new OPW Edael. 5 <br />TYPE OF SERVICE REQIfESTED: gallon Sp• " `et antSaig1J�� dJ oil Ito <br />rQ tilb y��� � PA <br />EHD 48.02-025 <br />07/97/0$ <br />SR FORM (Golden Rod) <br />COMMENTS: <br />V <br />At1G22 2 <br />$Rp <br />UIN COU <br />� 4L7y N SNr <br />ENVIR <br />/A. HI F, A! 11,i <br />ACCEPTED BY: <br />1 . <br />✓ ��. <br />I ` 4 <br />IW41 YEE #: %- <br />DATE: <br />�� / Mtr <br />ASSIGNED TO: <br />G1 <br />EMPLOYEE #: <br />DATE: <br />P'.!2 <br />Date Service Completed <br />(if already completed): <br />SERVICE CODS: <br />PI E: <br />Fee Amount, <br />O& <br />'10Amount <br />Paid��©� <br />Payment Date <br />�� <br />payment Type <br />Invoice # <br />Check #� <br />Rec <br />ived By: <br />EHD 48.02-025 <br />07/97/0$ <br />SR FORM (Golden Rod) <br />