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SAN JOAQUNWV/".OUNTY ENVIRONMENTAL HEALTI. 3 PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Delbert Rapini CHECK if BILLING ADORES <br /> FACILITY NAME Rapini Brookland Farms <br /> SITE ADDRESS 8800S. HenryRoad <br /> Street Number Direction Street Name Fermin ton Zip Cod. <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Stmet Ne <br /> CITY STATE ZIP <br /> PHONE#1 EaT APN# ELANDUSE APPLICATION#(209 ) 239-4908 187-400-21, 25, 26, 28, 2931 PA-03-22 <br /> PHONE#2 ExT DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR David Welch CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Neil O. Anderson 8t Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FAX Al <br /> 902 Industrial Lane (209 )333-8303 <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,Standar TA^and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �Mr <br /> N Neil O.Anderson&Assoc.Inc. DATE: May 26, 2004 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ <br /> ANAGER ❑ OTHER AUTHORIZED AGENT l4 Consultant <br /> If APPLICANT is not the BILLiNG PARTY proof of authorization to Sign is required Title P. <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the properltj� <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site sI <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and a1JV time 1 <br /> provided to me or my representative. //ii <br /> TYPE OF SERVICE REQUESTED:Review Of Soil Suitability and Nitrate Loading Study. FN ogQIJ <br /> COMMENTS: A report review fee of 465 is attached. If you have any questions regardingrg <br /> please do not hesitate to call. Questions regarding the percolation testing conducted MFNr <br /> NATS can be directed to David K e tner at (209) 545-11 Q8 or to our office. <br /> Best Regards, Dave Welch. % g� y 7�1� W� -7 100 Ad�A <br /> APPROVED BY: ( (-y slL. �iEMPLOYEEM (,,( DATE: G � <br /> ASSIGNED TO: -r'e"�r EMPLOYEE#: O DATE: J�� D t+'1 <br /> Date Service Completed (if aheady completed): SERVICE CODE: CSD-C=11 P I E: <br /> Fee Amount: Amount Paid Payment Date j <br /> Payment Type Invoice# Check# Received By: , <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />