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,F w <br /> SAN JOAQUIi, t'OUNTY ENVIRONMENTAL HEALTH lo oPARTMENT <br /> E <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ZDK 1*0 V U 4 3 <br /> OWNER 1 OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Khinda Pro ert <br /> SITE ADDRESS 27475 S Fair Oaks Tracy <br /> Street Number DirectionStreet Name Ci Zi Code y <br /> i <br /> HOME or MAILING ADDRESS (If Different from Site Address) 27000 Leward Way <br /> Street Number Street Name ' <br /> CITY STATE ZIP 95304 <br /> Tracv . --- . CA <br /> PHONE#1 EXT- `fir AAN# - LAND USE APPLICATION# <br /> 243-110-33-/ PA 05-28 (MS) <br /> PHONE#z EXT. / BOS DISTRICT LOCATION CORE ` <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS X <br /> BUSINESS NAME PHONE# EXT' <br /> Nem] O.-Andprsnn and Assodatps, Inc. (209)367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209)369-4228 <br /> CITYSTATE ZIP <br /> Lodi 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 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 ail SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ATE: Z C, Lj <br />- PROPERTY/BUSINESS OWNER❑ O ERATORIMANAG R ❑ OTHER AUTHORIZErt AGENT© Consultant <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Trite <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. pq <br /> TYPE OF SERVICE REQUESTED: Sail Suitability and Nitrate Loading Addendum <br /> COMMENTS: 1" Isp� /� 2 <br /> /7 RECEIVED S P x 5 <br /> 4005 <br /> SEP 2 3 200 �L <br /> , 4 VRo°Ut�c <br /> TyQ�p FN� NAY <br /> `J SAN JOAQUIN COUNTY RTNjq <br /> NVIRONMENTAL <br /> APPROVED BY: t 1 W—A EMPLOYEE M HEALTH ,.3 Gs <br /> ASSIGNED TO: �V A-A) 6 V/L1 E EMPLOYEE#: 0 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S 2 PIE: <br /> Fee Amount: 4 465.60 Amount Paid Payment Date <br /> Payment Type invoice# Check# ecelve ay: <br /> EHD 48-01-025 \L) �(� S SERVICE REQUEST FORM <br /> REVISED 6-5-02 `�\ <br />