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SAN JOAQUI4-OUNTY EN;1 YMENTAL HEALTH 1 ARTMENT <br /> I SERVIC: "REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 94 <br /> OWNER/OPERATOR <br /> Mr- Stan Robertson CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> 25122 South Banta Road Property <br /> SrrE ADDRESS 25122P S Banta Road Tracy 95304 <br /> Street Number Direction I Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS Jif Different from Site Address) 27337 South Banta Road <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Tracy <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> I } 250-220-02 PA-05-048 <br /> PHONE#2 - Ems• BOS DISTRICT=F LOCATION CODE <br /> I r YJl <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS® <br /> Dave Welch <br /> BUSINESS NAME PHONE# Exr. <br /> Nell 0- Anderson and Associates, Inc- (209)367-37ni <br /> HOME Or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209)369-4228 <br /> CITY STATE Zip <br /> Lodi CA 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> II 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,Stan r :TAIEand FEDERAL laws. <br /> i APPLICANT'S SIGNATU DATE: l —( <br /> PROPERTY/BUSINEss OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Constultant <br /> If APPLICANT 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 /> 6 provided to me or my representative. \ n,, <br /> TYPE OF SERVICE REQUESTED: Soil Suitability Study Review A4 <br /> � � �t}�� � <br /> COMMENTS: APR <br /> 2 0 2Dos <br /> Jo <br /> iE-NVtne Utiy CDU <br /> �� <br /> P�rur�MY <br /> APPROVED BY: OL t V (e--A- EMPLOYEE M Q 3 DATE: <br /> ASSIGNED TO: v EMPLOYEE#: (f DATE: <br /> Q` C{ <br /> Date Service Complete.&{if already complete -2— SERVICE CODE: Z I 0 !1 <br /> Fee Amount: �� mount Paid B Payment Date l �Q CJ <br /> Payment Type ✓ Invoice# Check# Re eived B <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />