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. . <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> " SERVICE REQUEST <br /> SERVICE REQUEST# <br /> t FACILITY ID# ��h <br /> Type of Business or Property `/ (� <br /> OWNER I OPERATORCHECK if—BILLINGADDRESS <br /> Leroy Cunningham <br /> FACILITYNAMECunningham Property <br /> =FRZipon95366SITE ADDRESS 6471 ��A�usbn Roadc e <br /> Street Number Street Marne <br /> HOME or MAILING ADDRESS (if Different from Site Address) 8836 Melton Road <br /> 1 Street Number Street Name <br /> STATE CA zip 95337 <br /> CIN <br /> Manteca LAND USE APPLICATION# <br /> PHONE#11 APN# <br /> 12091 519 4491 257-210-08 PA- 04-.10 {MS} . <br /> BOS DISTRICT � LOCAY�CODE <br /> PHONE#2 E 1? <br /> ( 1 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR Nancy R. Kramer CHECK if BILLINGADDRESS[D <br /> PHONE# EXr <br /> rUTSIENEFssNAME 209 367-3701 <br /> Neil O. Anderson &Associates Inc. FAx <br /> NG ADDRESS (209 1309_4228 <br /> 902 industrial Wa STATE CA ZIP 95240 <br /> Lodi <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 prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> PROPERTY I BusINESS OWNERO OPERA OR I MANA ER OTHER AUTHORIZED AGENT I3 <br /> If APPLICANT is not the BILLINGPARa 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: Soil Suitability Study Review <br /> COMMENTS: � ) � If1e,J <br /> 1 SEB 0 8 200 <br /> MN JOAOUIN COUNTY <br /> ENVIRONMENTAL <br /> t EMPLOYEE#: H DEP <br /> APPROVED BY: D <br /> ASSIGNED TO: /� EMPLOYEE#:. ( D'L — DATE: 0 <br /> f C1 T(�L�C._O � . <br /> SERVICE CODE: P I <br /> 1f Date Service Completed (if already completed):. �2— �O r <br /> Fee Amount: Amount Paid Payment Date g' D <br /> Payment Type Invoice# Check#` Received <br /> R SERVICE REQUEST FORM <br /> EHl7 48-41-425 <br /> S+ y <br /> REVISED 6-5-02 <br /> �., <br /> f <br />