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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE(UEST# <br /> Dry Warehouse <br /> OWNER/OPERATOR � <br /> t.I v 11 e'v yf':,.. L- <br /> FACILITY NAME CHECI<if BILLING ADDRESS <br /> 1 LL � <br /> SITEADDRESS 1 <br /> 9409 and 9612 Sugar Road San Joaquin County 95304 <br /> Street Number Direction Street Name it Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) r} �� y y}' j'�rr, <br /> Street Number �,� Street Name C �/ ,�j �-� .1 <br /> CITY STA ZIP ,?_!`�,✓ 1 <br /> PH NE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT S LOCATION CODE <br /> CONTRACTOR J SERVICE REQUESTOR <br /> REQUESTOR Paul Schneider CHECK if BILLING ADDRESS® <br /> BUSINESS NAME Siegfried Engineering, Inc. PHONE# EXT. <br /> 209 607-0710 <br /> HOME or MAILING ADDRESS FAX# <br /> 3428 Brookside Road ( ) <br /> CITY Stockton STATE CA ZIP 95219 <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 /> I also certify that I have prepared this ap lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Sta d, ATE an qE Laws. <br /> �'j <br /> fiPPLICAN'T'S SIGNAT E: 1 DATE. <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> Cf APPLICANT is not the BILaw 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentai/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and atle time it is <br /> provided to me or my representative. R r 7 <br /> TYPE OF SERVICE REQUESTED: Nitrate Loading Study Review Z <br /> COMMENTS: GoPost Number 3400 YV <br /> e)UI �IInSS , yFgcTV/R�NINCO <br /> ACCEPTED BY: LL EMPLOYEE#: DATE: <br /> ASSIGNED TO: AS EMPLOYEE#: DATE: a �� <br /> Date Service Completed (if already completed): SERVICE CODE: SaZ 3 PIE: a6 p oZ <br /> Fee Amount: (o p g Amount P �bg a� I Payment Date <br /> Payment Type Invoice# Check# `�/` Received By.ar <br /> /C� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />