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i <br /> irf <br /> SAN JOAQUIN­COUNTY ENVIRONMENTAL HEALTH LL.ARTMENT <br /> 4 • <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> ' FACILITY NAME <br /> Swickard Pro ert <br /> SITE ADDRESS 9499 Biederman Way. Escaion <br /> Street Number Directio Street Na Cit 7Fipoda <br /> HOME or MAILING ADDRESS Ilf Different from Site Address) 1379 Mosswood Avenue <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Es alon CA <br /> PHONE#1 Exr. . APN# LAND USE APPLICATION# <br /> (209)838-6223 205-190-22 PA-0500250 (SA) <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLINGADORE55❑ <br /> BUSINESS NAME PHONE# EXT• <br /> Nail 0- Anderson and AssockgtP& Inc. (909) 367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (2091369-4228 <br /> CITY Lodi STATE CA ZIP 95240 <br /> I 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 performedwiH be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: DATE- <br /> PROPERTY/BUSINESS OWNER® OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT 0 <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 Iocated at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environm4ntal/site assessment <br /> I information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it i$.1]�(tl �t the same time it is <br /> provided to me or my representative. j�l� <br /> TYPE Of SERVICE REQUESTED: Soli Suitability Study Review 5 <br /> I COMMENTS: <br /> 2ovw <br /> /Z�7�rJ77� remit j P <br /> AM SOHO AMEN ptLTM <br /> jI APPROVED BY: '-1 EMPLOYEE#: . DATE: <br /> S <br /> ASSIGNED TO: EMPLOYEE#: J DATE: <br /> Date.Service Cornpletdd (if already completed):. SERVICE CODE: P/ <br /> E: <br /> I - <br /> Fee Amount: Amount Paid Pa mentjIate' 0 <br /> I �� • O� y <br /> i Payment Type Invoice# Check# a(7 Received By: <br /> s <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> 1 REVISED 6.5-02 <br /> I <br />