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SAN JOAQ11J1r,r1k�OUNTY ENVI WNNtiIENTALHEALTH bi ARTMENT <br /> SERVICE REQUEST `�II <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> OWNER l OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Mr- Stan Robertson <br /> FACILITY NAME <br /> 25122 South Banta Road Property <br /> SITE ADDRESS 25122 ' ' l S Banta Road Tracy 95304 <br /> Street Number Ditection I Street Name city ZioCode <br /> HOME or MAILING ADDRESS (if Different from Sne Address) I <br /> 17 <br /> 27337 South Banta Road <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> r rCA 25376 <br /> PHONE#t ExT APN# r + LAND USE APPLICATION# <br /> 250-220`02 PA-04-596'&-PA- 8 <br /> rONE Exr. BOS DISTRICT' L CATION CODE <br /> I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dave Welch <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Neil Q- Andprgon nnd Associates, Inc. (209)367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209) 8 <br /> CITY Lodi STATE CA ZIP 95240 <br /> I <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 /> 1 also certify that I have prepared this ap I' t' and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standa STA and FEDERAL laws. / } <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 10 Constultant <br /> If APPLICANT is not the BILLING PARTY,proof Of authorizadon to sign IS required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,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 itis 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: Please review the following Soil Suitability Study. We hav�Fache�yfFl��sl�rvice rVl�00 <br /> I f$186. If you have any qyesppns please _a <br /> APPROVED BY: �LI V E 1 ,1 EMPLOYEE 1F: b 3 DATE: —3 <br /> ASSIGNED TO: �( y. �1r EMPLOYEE#: - / DATE: as- <br /> Date Service Completed (if already completed): ERVICE CODE: 5 � P I E: <br /> Fee Amount: 371-5 <br /> Amount Paid 0 D Pa rent Date <br /> Payment Type Invoice# Check# -1'1 LJ-7Received By: <br />! EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />