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SAN JOAQUi. 2OUNTY ENV_R0NIV':_Er1'-F;,L H ZALTH :PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property L FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Mr. Christopber Withrow, Phoal3ix Program, Inc- CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Phoenix Pro ram <br /> SITE ADDRESS 18325 S Airport Way MantecaT�' <br /> 337 <br /> Street Number Direction Sheet Name Ci i 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 /> Concord <br /> PHONE#') ExT• APN# LAND USE APPLICATION# <br /> ( ) 241-300-52 PA-04-384 c`F <br /> PHONE#T 6cT. ODE BOS DISTRICT LOCATION C <br /> ( ) q <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> Dave WaIlCh <br /> BUSINEss NAME PHONE# Exr. <br /> —Neil.Q. Anderson and Aq,.:;Qr0,qtes. Inc- ( 209)367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 2 Industrial Way (209) 69-4228 <br /> CITY Lodi STATE CA zip 95240 <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have preparedth• pp I atio and that the work to be p Q <br /> performed will be done in accordance with all SAN JOA UIN <br /> COUNTY Ordinance Codes,Standa s,ST E a FEDERAL laws. <br /> v <br /> APPLICANT'S SIGNATURE: ! �� F�I✓�.F i�ATE: <br /> PROPERTY/BUSINESS OWNER❑ tARATOR/MANAGER 13OTHER AUTHORIZED AGENT 13PAV a4EN'T <br /> IfAPPLICANT is not theLINGPARTY,proof of authorization to sign is required Title C lV <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/ it �S jste�ii, <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 /> SAN JCJ:A01JIN GC7.tJ,ti'= <br /> TYPE OF SERVICE REQUESTED: /tJ t I E ox 15,5 <br /> OF�L+1!N'D1"iFF?AftlCs <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 /> f Dave <br /> APPROVED BY: L.t t-A l EMPLOYEE#;. DATE: <br /> c D3 z 1 2— <br /> ASSIGNED <br /> ASSlGNEO TO: EMPLOYEE#: DATE: <br /> Date Service Complt ted (if already completed): SERVICE CODE' S2S PIE: <br /> Fee Amount: c (;5; Amount Paid C{(,�. C,C, Payment Date <br /> Z rS OS <br /> Payment Type NieLCE Invoice# Check# C12-7. Received By: �-7 <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED B-5-02 <br />