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4 y <br /> SAN JOAQU�.. COUNTY ENVIRONMENTAL HEALTH- PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �o q <br /> OWNER/OPERATOR <br /> ' CHECK If BILLING ADDRESS <br /> Mr- Stan Robprtqc)Li <br /> FACILITY NAME <br /> Robertson Pro ert <br /> SITE ADDRESS 28200 S Banta Road Tracy 95304 <br /> Street Number I Directi Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 27337 South Banta Road <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Tracy CA 95376 <br /> PHONE#t EST. APN# LAND USE APPLICATION# <br /> ( 1 252-110-17 PA-04-091 <br /> PHONE#Z <br /> EXT. BOS DISTRICT 'LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Dave Wp-lr-h <br /> BUSINESS NAME PHONE# EXT' <br /> iNeil 0- And -rqon aod Agsoe'ates, Inc (209)367-3701 <br /> HOME Or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209)369-4228 <br /> CITY STATE CA ZIP 95240 <br /> —Lod <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 ' tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar TAT and FE n RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT 0 Consultant <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. <br /> TYPE OF SERVICE REQUESTED; ,�,O f L <br /> COMMENTS: Please review the following Soil Suitability Study. I attaC the "NED <br /> review fee pf$186. If you have any questions please call. ftr <br /> � �e.•�t.� �� �. 8 2005 <br /> AN JOAQUIN COUN <br /> APPROVED BY: .. EMPLOYEE#: DATE: T EN <br /> C} �I � �c �2�4- "�/ <br /> ASSIGNED TO: f7 � � EMPLOYEE#: G DATE: I (� <br /> Date Service Comppleted (If already completed): SERVICE CODE: SZ Z PIE: <br /> 1 Fee Amount: [ewAmount Paid b Payment Date <br /> - <br /> Payment Type invoice#, Check# �'7 }S' Received By: <br /> EHD 48-01-026 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />