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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST# <br /> Fuel dispensing station , SR a. 5017 25 <br /> OWNER I OP OR <br /> CHECK It BILLING ADDRESS <br /> FACILITY NAME <br /> George Kishida <br /> SITE ADDRESS 1725 Ackerman Drive Lodi 95240 <br /> Street Number 01ructiqn Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Numtwr Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> M16 1368-0603 14 i <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR �_ Y <br /> REQUESTOR r <br /> CHECX if BILLING ADDRESS <br /> BUSINESS NAME PHONE E T• <br /> IiW Msiintennnce 916 J 371.2360 <br /> HOME Or MAILING ADDRESS FAx <br /> PO Box933 ( 1 <br /> CITY STATE Zip <br /> 3n:ran�rnv CA <br /> 65n91 <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 ENVIRONNI NTAL 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 /> XAPPLICANT'S <br /> COUNTY Ordinance Codes, Standards, STATE and FEDEftA I <br /> SIGNATURE: DATE: �i <br /> PROPERTY/ BUSINESS OWNER ❑ OPERATOR i MANAGER ❑ OTHER AUTHORIZED AGENT ❑ VAN�' <br /> If APPLICANT i5 not the BILLING PARTY. PfOof Of authorizaXion to sign is required Tert a F ♦O <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable. I, the owner or operator of the property to a�th�a <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assess rtY Ion 0?� <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soot/ as it IS available end at the same time it i <br /> my representative. 60 <br /> (� /� T1/ NMF U/Vry <br /> TYPE OF SERVICE REQUESTED: S� I Q� <br /> COMMENTS: _ <br /> DTP A�b <br /> rACFP rEn 13Y- , i 1� A 71 EMPLOYEE #: v DATE: ' <br /> ASSIGNED TO: Myaedt �Vl rn�J (,� �7 EMPLOYEE #: DATE; <br /> Date Service Completed (it already completed): L' SEaVICE CODE: p I E; Q <br /> Fee Amount: 1 l t> Amount;Paid r Paymen:tD <br /> te <br /> Payment Type Invoice # Check # 3���, I_ Received By: <br /> EHD 48-02-025 <br /> 5R FORM (Golden Rod) <br /> 07117106 <br />