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SAN JOAQi('COUNTY ENVtRONMVNTAL HEALTI- EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OV4ER 1 OPERATOR <br /> CHECK if BILLING ADDRESSED <br /> FACILITY NAME <br /> SKS Enterprises Incor orated <br /> SITE ADDRESS 2370 E Brandt Road Lodi 95240 <br /> Street Numher Direction Street Name Ci Zi Code <br /> HOMF�r MAILING ADDRESS (if Different from Site Address) <br /> ! -0 - Street Number Street Name <br /> CITYS TE zip <br /> I �� <br /> I PHONE#1 EXT APN 1F LAND USE APPLICATION# <br /> W) 9S8_ 023 170-08, 023-180-01, 023-190-03 PA-04-365 <br /> PHONE EXT. BOS DISTRICT CATION CODE <br /> LO <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESSO <br /> BUSINESS NAMEPHONE# Exr. <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way 120 1369-4228 , <br /> CITY STATE zip <br /> LodiCA 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 me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work a performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard TA and FEDERAL la <br /> APPLICANT'S SIGNATUI .E: DATE: <br /> PROPERTY I SL7SINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> ,IfAPPLICANT iS not the BILLING GP <br /> proof o authorization to sign is required Tiite <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 /> TYPEoFSERVICEREQUESTED: Soil Suitability and Nitrate Loading Review PAYMENT <br /> CoMNrENrs: ---IRECEIVED <br /> The nitrate and DBCP water test will be sent separately when results are available. <br /> DEC 2 -S 2005 , <br /> SAN.30AQUlN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED B EINPLOYEE#: 0(9[t/ DATE: J Z—�p-$[/ <br /> � <br /> ASSIGNER TO: �+ EMPLOYEE M t lV DATE: J Z L tl JQ <br /> Date Service Completed (if already completed): SERVICE CODE: P!E: <br /> Fee Amount: Amount Paid <br /> v O Payment Date 1 <br /> Payment Type ✓ invoice# Check# �� Received y: Llf <br /> REVEVID SED 60-0 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />