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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> HEALTHCARE FACILITY ,n DaC'lC1 <br /> OWNER / OPERATOR <br /> WILLIAM HAENA CHECK If BILLING ADDRESS El <br /> FACILITY NAME <br /> KAISER STOCKTON <br /> SITE ADDRESS WEST LANE STOCKTON 95210 <br /> 7373 Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> GREG SLUNAKER CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT• <br /> TANK-TEK ENVIRONMENTAL CORP ( 951 ) 779 -4999 110 <br /> HOME or MAILING ADDRESS FAX # <br /> PO BOX 5850 ( 951 ) 788 - 7089 <br /> CMVERSIDE STATE CA ZIP 92517 <br /> BILLING ACKNOWLEDGEMENT : I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project Zp <br /> ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my buidentified on this form. <br /> I also certify that I have prepared this ap2FEDE <br /> the o k to be perfo ed will b done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, dL w . <br /> APPLICANT ' S SIGNATURE : DATE : 8/21 /2023 <br /> PROPERTY / BUSINESS OWNER ❑ E OR / MANAGER ❑ OTHER AUTHORIZED AGENT CLI CONTRACTOR <br /> IfAPPLicANT 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative . <br /> TYPE OF SERVICE REQUESTED : SST PA y <br /> COMMENTS: CLSI �/t ,jEF D <br /> AUG 23 ?023 <br /> NE�yAONMENlUNT <br /> Y <br /> 41 <br /> ACCEPTED BY: EMPLOYEE #: DATE : <br /> ASSIGNED TO : l EMPLOYEE # : DATE : 8 22 Z3 <br /> Date Service Completed (if already com leted) : SERVICE CODE : PIE : 2ZO O <br /> Fee Amount: Amount Paid 9LLV/ � Payment Date z4 <br /> Payment Type U� Invoice # Check # 1 .754S,57/ D Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 / 17/2003 <br />