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s. .SAIYeTOAQUL__� OUNTY ENV ONNIENkF ALHEALTH`i�;PARTMENT <br /> SERVICE REQUEST <br /> r Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK H BILLING ADDRESS <br /> FACILITY NAME <br /> Phoenix Pro ram <br /> SITE ADDRESS 18325 S Airport Way Manteca 95337 <br /> Street Number Dir t' n ret Name city 7ip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1875 Willow Pass Road No. 300 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Conggrd CA 94520 <br /> PHONE#1 Err. F24"41-300-52 <br /> PN# LAND USE APPLICATION# <br /> PA-04-384 <br /> PHONE#2 ExT• BOS DISTRICT - LOCATION CODE <br /> r I q <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Dave Welch <br /> BUSINESS NAME PHONE# ExT• <br /> Neil 0- Andpi-srIn ;and Associates. Inc. (209)367-37()l <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial W 1209 f 369-4228 <br /> CITE' \ STATE ZIP <br /> CA <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 th' pp I ati0 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standa s,ST E a FEDERAL laws. <br /> APPLICANT'S SIGNATURE: lel. ��I ATE• <br /> PROPERTY I BUSINESS OWNER❑ P RATOR I MANAGER ❑ OTHER AUTHORIZED AGENT© I "[� <br /> IfAPPLiCANT is not the LING PARTY proof of authorization to sign is required Title FiE.CENED <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 andor environmental/ RsIssbeoi., <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at theCsaGme time it is <br /> provided to me or my representative. 1; SAN.1p4t�ft '� <br /> TYPE OF SERVICE REQUESTED: SSS l T <br /> /v 1 1�'—�^4%E C_U�4.Q t n7�- S [e7yL 'i 14&�' TI <br /> COMMENTS: Please review the following Soil Suitability Study/Nitrate Loading Study. Mr. Withrow will <br /> attach the service review fee of$465. If you h ve any questions please call. <br /> Dave90 <br /> APPROVED BY: D L[lJ [T�.>T, EMPLOYEE#: DATE: <br /> ASSIGNED TO: �f./r .N� . EMPLOYEE#:. DATE: <br /> Date Service Completed'(if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid <br /> t b 5 t3 t`3 �S v i�..; Payment Date <br /> Payment Type Invoice# . Check# X77: Received By: G� <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />