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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> 5+ 000 40 C q 1 5Z013� 1� y [ <br /> OWNER / OPERATOR <br /> Pacific Gas & Electric CHECK If BILLING ADDRESS <br /> FACILITY NAME Pacific Gas & Electric <br /> SITE ADDRESS 4040 West Lane Stockton 95204 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> PO Box 7640 Street Number Street Name <br /> CITY San Francisco STATE CA ZIP 94120 <br /> PHONE #1 Exr• APN # LAND USE APPLICATION # <br /> ( 209 ) 262-0164 117-020-01 <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Kristin Reynolds CHECK if BILLING 199 <br /> BUSINESS NAME TAIT Environmental Services , Inc PHONE # ExT• <br /> 916 224-7280 <br /> HOME or MAILING ADDRESS 11280 Trade Center Drive FAx # <br /> CITY Rancho Cordova STATE CA ZIP 95742 <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 /> rk ""'� " `"° ""w" 6/ 16/2022 <br /> APPLICANT' S SIGNATURE : Kristin Reynolds ode � �-0ar <br /> DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Contractor- Regional Director <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 i mation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is prOVl d �P(� Ar <br /> my representative . �c� T <br /> TYPE OF SERVICE REQUESTED : USE 91tft? ) 74 <br /> D CD <br /> COMMENTS : S4 JV (J <br /> y A� V R0 USN COL <br /> 2 Z <br /> TyOFFgR�� TY <br /> T <br /> ACCEPTED BY: EMPLOYEE M DATE: /J /L <br /> ASSIGNED TO : r /1 ` EMPLOYEE # : DATE: <br /> Date Service Com ted (if already completed) : SERVICE CODE: IVY �� �% PIE: <br /> Fee Amount: Amount Pai zLPayment Date77 TO 4v 06 <br /> Payment Type Invoice # Check # �c fsJ S 27Z Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />