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� t � <br /> I .SANJOAQUIN COUNTY E>1VIRONMENTALHEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1 <br /> OWNER I OPERATORt <br /> CHECK if BILLING ADDRESS® <br /> FACILITY NAME <br /> Khanshali Pra ert <br /> SITE ADDRESS 9542 S Airport Way Manteca 95336 <br /> Street Number Direct• Street Name cityZi code <br /> HOME or MAILING ADDRESS (If Different from Site Address) dd <br /> Street Number Street Name <br /> STATE ZIP <br /> CITY t <br /> PHONE#t SXT FAP7N# LAND USE APPLICATION# <br /> -08-10 & -09 05-420 SA (Pre-application) <br /> PHONE#2 EXT. $OS DISTRICT LOCATION CODE <br /> [ 1 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> Neol 0- 8nderson and Associates. Inc- (20A)367-370 <br /> FAX <br /> HOME or MAILING ADDRESS [ #913 -4228 <br /> 902 Industrial Way <br /> CITYSTATE ZIP <br /> 11Lodi QA 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. I <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. I' <br /> XAPPLICANT'S SIGNATURE ) 1 DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT ' <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. PAYM ENT <br /> i TYPE OF SERVICE REQUESTED: Spoil Suitability & Nitrate Loading Stud Review <br /> COMMENTS: I �7 D.6 F�CwAtv� 6�ri^r✓" �L �Zi�JI . �1l�yt�� JAN I 1 2006 <br /> L ' 3- aG �nrs)• c� �@ le#c.� Sol Sufi � �•�era�rr-vAZW f�J/�Xv OUIN co <br /> U� SAN JOA <br /> ENVIRONMENTAL <br /> EALT <br /> Le41�" 'i�•r,�J�__++,,'w,'s��fsss✓✓✓ Ii pEPARTME <br /> F <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO. EMPLOYEE#: DATE: f !r <br /> Date Service Completed (if already completed): SERVICE CODE: P I <br /> ` Fee Amount: /` Amount Paid 5, Payment Date l� <br /> Payment Type t� . Invoice# Check# Ad.3 s Recelved By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />