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I <br /> SAN JOAQUIN'COUNTY EhIVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> ` -FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property <br /> S f200 <br /> OWNER I OPERATOR CHECK if BILLING ADDRESsE <br /> FACILITY NAME <br /> Seciura Pro ert <br /> SITE ADDRESS 24195 S Cabe Road Tracy 9 304 <br /> Stmet ber Direction treet Name Ci Zi Code <br /> (If Different from Site Address) 5158 Nile Road <br /> ;rug Street Number Street Name <br /> C Imr STATE ZIP <br /> Manteca <br /> PHONE#t EST• APN# LAND USE APPLICATION# 01 a <br /> (209)986 7600 205-160-05 � �!#' <br /> I PHONE#2 Err- BOS DISTRICT"" LOCATION COD€ <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Nancy ROSUIeI( CHECK If BILLING ADDRESS[] <br /> BUSINESS NAME PHONE# ExT' <br /> Neil O. Anderson &Associates 701 <br /> - <br /> HOME or MAILING ADDRESS FAX# <br /> 209 369-4228 12091 -422 <br /> CITY Lodi <br /> STATE CA -ZIP <br /> 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 to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar STATE and FEDERAL laws. <br /> I <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY IBUSINESS OWNER❑ OPERATORI ZNAGER ❑ OTHERAIITHORIZEDAGENT <br /> ® <br /> If APPLICANT 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. _ _ _ _ _ _ PAYMENT <br /> RECEf ED <br /> f <br /> TYPEOF SERVICE REQUESTED: Sall Suitability I Nitrate Loading Study F, <br /> COMMENTS: <br /> 31,;7,16764C 3 MAR 2 2006 <br /> , w RUSH SAN COUNTY <br /> ,3/ ENVIRONVIRON ENTAL <br /> 1��I11.�Y\ �y.(/!✓f HEALTH DEP RTMENT <br /> APPROVED BY EMPLOYEE#: DATE: ,,�3 <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO T <br /> .:. <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> ZS=� �a7 <br /> Fee Amount: 8"s"' `Amount Paid Payment Date <br /> aA; a <br /> Payment Type Invoice# Check# .'.'fj t]� Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> r REVISED 6-5-02 <br /> i �� <br />