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SAN JOAQU>.,OUNTY'ENVIRONMENTAL HEALTH*.,�PARTMENT <br /> SERVICE REQUFST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S /Z 9& 'JWg-C) <br /> OWNER/OPERATOR Kenneth Skibo CHECK If BILLING ADDREssQ <br /> FACILITY NAME <br /> SITE ADDRESS 27570 N. Mackville Clements 9S�-Z7 <br /> Street Number I Direction Street Name Cit L Gotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Sheet Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t Ez. APN# LAND USE APPLICATION# <br /> (209 ) 747-4648 009-110-04 PA-04-89 <br /> PHONE#2 0[r. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR David Welch CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# Exr' <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FAX# <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,Standards,STATE and FEDERAL laws. <br /> x APPLICANT'S SIGNATURE: >/Z- �. DATE: 7 - If - O Y <br /> 1 PROPERTY/BUSINESS OWNER®� OPERATOR/MANAGER OTHER AUTHORIZED AGENT[I <br /> If APPLICANT is not the BILLING PARTY proof of authorization to 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 /> TYPE OF SERVICE REQUESTED: Soil Suitability Study report review. R MF <br /> COMMENTS: Mr. Kenneth Skibo will pay the 186 report review fee. p <br /> ` bFL 15 2004 <br /> SANJ <br /> ism..-rl HI�qIvH M� <br /> APPROVED BY: EMPLOYEE#: DATE: ��Q <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ��z P 1 E: <br /> Fee Amount: Amount Paid -- Payment Date <br /> Payment Type Invoice# Cheek#C� Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />