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• ar � <br /> _4..SAN JOAQUIN COUNTY ENV,CRONI ENTAL HEALTH DEPARTMENT <br /> SERVICE R&QUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNERI OPERATOR <br /> Poeun Hib CHECK ifBILLING ADDRESS <br /> ® <br /> FACILITY NAME Carpenter Road Buddhist Temple <br /> SrrE ADDRess3732 E95215 <br /> Carpenter Road Stockton <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILINI3 ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> ! CITY STATE ZIP <br /> PHONE#t Err. APN# LAND USE APPLICATION# <br /> 179-160-49 <br /> PHONE#2 ExT• =DISTRICTLOCA&�CODE <br /> Vt'• ( 1 Z- <br /> �A CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Nancy R. Kramer CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ext• <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way 12091369-4228 <br /> t CITY Lodi STATE CA ZIP 95240 <br /> I BILLING ACKNOWLEDGEMENT: 1, 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,Stan TE and FEDERAL laws.kk SIGNAT RE: DATE: <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT 17 <br /> If APPLICANT is not the BILLING PARTY,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 <br /> I information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available aild at the same time it is <br /> provided to.me or my representative. <br /> I TYPE OF SERVICE REQUESTED: Soil Suitability 1 Nitrate Loading Study <br /> k COMMENTS: <br /> SA a� <br /> PgRAt <br /> t� <br /> APPROVED BY: ©l.+C !K�Pr EMPLOYEE#: DATE: Z3-a <br /> ASSIGNEDTO: E� y�� EIMPLWEE#: 73 7 DATE: <br /> j Date Service Completed (if already completed): SERVICE CODE: s � P I E: (� <br /> ee <br /> FAmount: � Q�^ - Amount PaiS D Payment Date 2 3 <br /> I d.. <br /> Payment7y.pe Invoice# Check# Received By: W <br /> i ' <br /> 1 <br /> EHD48-01-025 SERVICE REQUEST FORM <br /> *t°` REVISED 6-5-02 <br /> 1, <br />