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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT i <br /> SERVICE REQUEST <br /> Type of Business or Property I <br /> FACILITY 16.0 8ERM CE REQUEST <br /> OWNER I OPERATOR <br /> Jack Mah CHECKif )LLiNGADDRESS® <br /> FACILrrYNAME Jack's Place <br /> i <br /> SITE ADDRESS 7618 <br /> W; Eleventh St. Tracy �I 95304 <br /> Street Number Direction Street Name ' <br /> HOME or MAILING ADDRESS (If Different from Site Address) zipcode <br /> 7939 Eleventh St. <br /> Street Number Street Name <br /> C" Tracy STATE CA ZIP 95304 <br /> PHONE#'i Exr. APN# <br /> (209 832-3392 LAND USE APPLICATION# <br /> OJ 250-150-�4 PA-03-159 <br /> PHONE#2 EXT. <br /> ( ) SOS'DISTRicr <br /> LOCATION i CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RE_QUESTOR <br /> David Welch CNECKi(BILLIN� GADDRESSO <br /> BUSINESS NAME <br /> Neil O. Anderson &Associates Inc. PHONE# EXT, <br /> HOME Or MAILING ADDRESS 209 367-3701 <br /> 22 Houston Lane FAx#( 20)) 333-8303 <br /> C Lodi STATE CA ZIP 95240 <br /> ING ACKNOWLEDGE <br /> SICCMENT: 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,Standard TATE and FEDERAL <br /> _ l <br /> APPLICANT'S SIGNATUR i <br /> DATE: ��f <br /> PROPERTY I ElusmFSS OWNER OPERATOR I MANAGER © OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AlEMORIZATION 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 /> TYPE OF SERVICE REQUESTED: �� <br /> COMMENTS: A �� <br /> t Please review the attached Soil Suitablil y/Nitrate Lo Ing Study. Mr. Mah or 'GES. <br /> architect will pay the report revie , e of$465. <br /> GOV <br /> APFR4VEA BY: <br /> PN apPp44a`j pP l� <br /> j EMpLaYEE#:, DATE: <br /> AssII mEn TO: <br /> EMPLOYEE vEE#: <br /> DAI E: <br /> Date ServIC C m leted (if:alrea.ly complete } <br /> SERVICE CODE: — PIE: <br /> Fee Amount, . <br /> Amount Paid: LS,p L7 Payment late <br /> Payment Type Invoice 9 Che��# ,Jf 7 1-0 <br /> 3533 rr etved.By., <br /> EHD 48-01-025 <br /> REVISED 6-5-02 SERVICE REQUEST FORM <br /> 1 <br />