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SAN JOAQU. '.OUNTY ENVIRONM ENTAL FIEALTL sPARTMENT <br /> ., tl <br /> SERVICE RlUEST <br /> Type of Business or Property b ALITY ID# SERVICE REQUEST# <br /> h4a vi&kfac4ur!Ng <br /> P� <br /> OWNER/OPERATOR <br /> Hanson Pipe CHECK If BILLINGADDRESS <br /> � <br /> E FACILITY NAME Hanson Pipe <br /> SITEADDRESS 12405 E. Brandt Rd. Lackeford 95237 <br /> St Number Direction Street Name Ci Zi Code <br /> HOME <br /> or MAILING ADDRESS (If Different from Site Address) <br /> ve.,,1yeSfreetNumber Street Name <br /> CITY SrarE .G,�ZIP <br /> PHONE#1 En, APN# LAND USE APPLICATION# <br /> 051-320.06 PA-03-507 <br /> i PHONE#2 ExT- BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR j <br /> I.. REQUESTOR <br /> Abby Racco CHECK If BILLINGADDRESSE] <br /> BUSINESS NAME PHONE# EXT. <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FAx# <br /> 902 Industrial Way ( 209 333-8303 <br /> CITY Lodi STATE CA zIP 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 roe or my business as identified on this fo <br /> I also certify that I have prepared this application and e w 0 p formed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand ATE and EDE lI <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/MANAGER OTHER AUTHORIZED AGENT® PL(�'Or-4E��Ilvt2e�` <br /> If APPLICANT iS not the BILLINGPARTY,proof of authorization 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 i <br /> information t0 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 /> s <br /> TYPE OF SERVICE REQUESTED: Mf>�eD <br /> COMMENTS: Please review the attached Soil Suitabi ' y/Nitrate Lo ing Study. Please note that M & H <br /> Builders is our client for this job and will be submitting the report review fee of$465. Our <br /> contact at M & H Builders is Rick Haddock, 916-532-2597. If ou have any questions, <br /> please do not hesitate to call our office. Abby <br /> /, / <br /> APPROVED BY: EMPLOYEE#: �7//l DATE: <br /> ASSIGNED To: n _ E.MPLOYEe#: L 111fff DATE: <br /> Date Service Completed (if already completed)° SERVIGECODE: P I E-. <br /> Fee Amount_ Amount Paid Payment Hatt? <br /> Payment Type ✓P,A N4@o"# Check# Re eived ByZ7: <br /> EHD 48-01-025Jfj�ry 2 �J 200 SERVICE REQUEST FORM ; <br /> REVISED 6-5-02 APR f� 9 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL d <br /> HEALTH DEPARTMENT- - <br />