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I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR Dominic DePalma <br /> CHECK If BILLING ADDRESS® <br /> FACILITY NAME DePalma Farms <br /> SITE ADDRESS <br /> 18406 S. Hazelhurst Road Escalon <br /> Street Number Drection SUeet Name City Zip COAs <br /> HOME or MAILING ADDRESS (If Different from Site Address) 18666 East Highway 120 <br /> Street Number eat Name <br /> CITY Ripon STATE CA Zip 95366 <br /> PHONE#i En. APN# LAND USE APPLICATION# <br /> ( 209) 838-7034 245-080-07 Ppr- 010 050i(P <br /> PHONE#2 En. CGS D!STRICI LOCA TIgN CODE <br /> 1 1 � 5' <br /> CONTRACTOR / SERVICE RE UESTOR <br /> REQUESTOR I//// <br /> S o q If BILLING ADDRESS® <br /> BUSINESS NAME 'l PHONE# ExT <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 Z'P 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 /> 1 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, E and FEDE L laws. /( <br /> APPLICANT'S SIGNATURE: DATE: IV I7 f <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization f0 Sign is required Title <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. <br /> TIDE OF SERVICE REQUESTED: c�L.L.I�-F.4C - ES£Lt.lL�-CP C[JNT,A-M�r�,r��TL��Y <br /> COMMENTS: �I t y /a CFj�.N�' 015 <br /> OCT 1 9 2007 <br /> W" SAN JOAQUIN COUNTY <br /> 666 ENVIRONMENTAL <br /> HEALTHEPA/RT <br /> APPROVED BY: OSI U ((�1�.- EMPLOYEE#: (�-JA DATE: 6 U !GZ/ G <br /> ASSIGNED TO: "'f-' ( L)�0 L(L-o EMPLOYEE#: � tEls DATE: 6 U (/' Gl(0 <br /> Date Service Completed (if already completed): SERVICECODE: 3-j S' P I E: l �3 <br /> Fee Amount: 6 L?6, L-L) Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />