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r SAN JOAQUIN COUNTY ENVIRONMENTAL}."-E-*-7-[1TDFPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F;an A i 5kqq 6LZ- <br /> OWNER/OPERATOR CV104 ev m VpY. <br /> iC$ r jF ILLINGADDRESS <br /> FACILITY NAME <br /> UNSTATE EQUIPMENT C MPANY <br /> SITE ADDRESS 9948S HARLAN ROAD FRENCH CAMP 95231 <br /> Street Number tl n t Name i otle <br /> HOME Or MAILING ADD (N DIHe n from Site Atd reqs) <br /> ' . I Street Number Smeet Name <br /> CITY STATE zip <br /> LODI CA 95240 <br /> PHONE#1 EiT. APN# LAND USE APPLICATION# <br /> (209)334-2332 193-270-17 PA-06-617 (SA) <br /> PHONE#Y EXT. BOS DISTRICT LOCATION CODE <br /> I I CCL o <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REDUESTOR <br /> CHECK N BILLING ADDRESS <br /> Nancy Rosulek <br /> BUSINESS NAME PHONE# Eir. <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209)369-4228 <br /> CITU STATE CA zip 95240 <br /> 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,StandardsATE EDERAL laws. <br /> APPLICANT'S SIGNATU <br /> rrR <br /> �E' <br /> � DATE: Z ' <br /> PROPERTY/BUSINESS OWNERIIM OPERATOR/ NAGER ❑ OTHER ALITHOREZED AGENT❑ <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 /> Information t0 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 REOUUIESTED: SOII Suitability/ Nitrate Loading Study Y(VIENT <br /> COMMENTS:N L/S S ( u O -�IL <br /> FEB 2 6 2007 <br /> SAMENIfAL <br /> N N C <br /> tAOUNV <br /> ENVtRVIROEP RTM NT <br /> APPROVED BY: (✓r L I t l I IQ EMPLOYEE#: O 'l)Z.. ATE 2 Z(o(07— <br /> ASSIGNED <br /> 07ASSIGNED TO: . ZE,J EMPLOYEE#: 'j 37 DATE: 2,1Z,& <br /> Date Service Completed (N already completed): SERVICE CODE: 625 P I E: <br /> Fee Amount: r/ter- ill Amount Paid 16 � S DO Payment Date D-7 <br /> Payment TypeI/d Invoice# Check# rj �s OO Re eived By: /L� <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />