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SAN JOAQUIN COUNTY ENVIliONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUGEAST# <br /> 1 '( <br /> OWNER/OPERATOR <br /> Dirk Dykxhoorn CHECKHBILLING ADDRESS� <br /> FACILITY NAME <br /> SITE ADDRESS 6902E French Camp Road Manteca 95336 <br /> Street Number Street Name city Code <br /> HOME or MAILING ADDRESS (N Different from Site Address) 10774 Carrolton Road <br /> Street Number Street Nam <br /> CITY Escalon STATE CA ZIP 95320 <br /> PHONE#i En. APN# LAND USE APPLICATION# <br /> (209 ) 838-2668 206-050-03 "o -rrI bd/6 -;1 '`> <br /> PHONE#2 T BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R.EOUESTOR Tamara Woods CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# En. <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209 )369-4228 <br /> CITY Lodi STATE CA ZIP 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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> � y� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT� (� �VI 1)S <br /> /r APPLICANT is not the BLLLLNG 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 /> 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 SERVICER QUESTED: JV /U <br /> COMMENTS: 4 �y AOWP- /�11.�_ :Z RE IV <br /> 7 ��� �`'� 3� l� P"C-- MAR 1 2 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL T <br /> APPROVED BY: EMPLOYEE M DATE: 3 <br /> ASSIGNED TO: / , .-5 a D EMPLOYEE#: a L DATE: <br /> Date Service C mpleted (if already comp) od): SERVICE CODE: '7 ! P I E: O <br /> Fee Amount: U Amount Paid 9 � , Payment Date 3 2 O1 <br /> Payment Type ✓ Invoice# Check# a 3 -1 Received By: �, <br /> EHD 48-M-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />