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II <br /> w SAN JOAQUL-i COUNTY ENVIRONMENTAL HEALTH iiEPARTMENT T� <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER IOPERATOR ' <br /> CHECK if BILLING ADDRESS© <br /> Mr- Eric Holden <br /> FACILITY NAME <br /> Holden Pro e-rt <br /> SITE ADDRESS 16220 E Brandt Road Lodi 95240 <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS {If Different from Site Address} PD Box 934 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Lockeford CA 95237 <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> I I053-100-10 - o� - r <br /> PHONE#2T BOS DISTRICT LOCArCODE <br /> I I <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Nancy R- Krarnpr <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS' FAX# <br /> 902 Industrial Way (2 09)369-42,28 <br /> CITYII STATE ZIP <br /> Lode CA 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 Ile or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQutN <br /> COUNTY Ordinance Codes,I Standards,ST FEDERAL laws. <br /> Is <br /> APPLICANT'S SIGNATURE: DATE: I-31 07 <br /> PROPERTY/BUSINESS OWNE <br /> � 11 <br /> RM OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 0 <br /> Iff1PPLICANT is not the BILLiNGPARTY,proof of authorization to sign is required Title <br /> ,F <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. EST <br /> TYPE OF SERVICE REQUESTED:'SOII Suitabili Study <br /> R�CEtiv <br /> COMMENTS: ' FEB � -7 <br /> lNUd+ <br /> SAN JC)PQUa4 <br /> i! HF-A�H Dip RTMEN <br /> II <br /> APPROVED BY: (�1 t✓[. kJ EMPLOYEE#: (�' ?Zr DATE: ( '7 <br /> ASSIGNED 70: r� r .�4 EMPLOYEE#: DATE: r Qj 7 <br /> Date Service Completed (if already completed): SERVICE CODE: 2-,- PIE: <br /> Fee Amount: ' Amount Paid Payment Date <br /> l.q� rJ � � � r5b . , b� <br /> Payment Type t� Invoice# Check# , Z. 1 Received By: Cr° <br /> EHD 48-01-025 SERVICE REQUEST FORM ' <br /> REVISED 6-5-02 <br /> fi <br /> :fi <br />