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y SAN JOAQUfN %,OUNTY ENVIRONMENTAL HEALTH U PARTMENT <br /> SERVICE REQUEST 3,1 <br /> Type of Business or Property = FACILITY ID# -. SERVICE REQUEST#w <br /> k - °'• - e <br /> OWNER 1 OPERATOR <br /> Mr- Edwards i` CHECK If BILLING'ADDRESS <br /> FACILITY NAME <br /> Edwards Pro rt <br /> SITE ADDRESS 23544 S <br /> Banta Road Tracv 95304 <br /> Street Number Direction_ ame - GI - <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number .. Street Name <br /> CITY STATE "ZIP <br /> PHONE#1 ExT•__- - APN# - LAND USE APPLICATFON-# <br /> I } <br /> 1250-120-04 - PA-04=045 <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE' <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REDUESTOR <br /> - CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> HOME or MAILING ADDRESS - w FAX# <br /> 902 Industrial Way 1209)369 74228 - <br /> CITY STATE T zip <br /> Lodi &A 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 prepared this application and that the work_ to be performed will be done inacco_rdance with all SAN JOAQUIN' <br /> COUNTY Ordinance Codes,Stand TE and FEDERAL laws. <br /> APPLICANT'S SIGNATU DATE: <br /> PROPERTY/BUSINESS OWNER PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Consultant I <br /> IfAPPLic_4NT is not the BimNGPAj?Ty,proof of authorization to sign is required 'Title i <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,the owner or operator ofthe property located at the { <br /> above site address, hereby authorize the release of any and all results, geotechnical:data and/or environmental/site assessment J <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it is j <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: p <br /> IL S Lc 17 -A 1 L. <br /> COMMENTS: <br /> Please review the following Sail Suitability Study. We will attach Tview fee of <br /> D <br /> $186. If you have any questions please call. A <br /> Dave �71d-1611&8 y FEB <br /> 0 ,SAN Ja <br /> APPROVE grcBY EMirLQYEE#: 0- ENItIRQN SAL [7� <br /> �.L:t dmf I�f{ k-lEAI.TH DE <br /> yt .. - <br /> ASSIGNED TO: " EMPLOYEE# DATE:. <br /> afe Sera` .- <br /> �f c�Ear r .. <br /> 2- <br /> P <br /> cE �jS <br /> ice Completed (if already competed) _ 5ERVICE CODE: <br /> Jr P 1 E: <br /> Fee Amoupnt ' i ', 'O Arun#Paid of.` $' Payment Date Ill <br /> r _rio:. <br /> Paymenf type s Invoice# = Check# `7 Received By:' <br /> EI iD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />