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SAN JOAQ0Prt'COUNTY ENVIRONMENTAL H EALTHa.,EPA RTM ENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SRO09S1 -73 <br /> OWNER/OPERATOR <br /> Mr. Mike Terpstra CHECK If BILLING ADDRESS <br /> FACILITY NAME Terpstra Property <br /> SITE ADDRESS 26222 E. Mahon Ave. <br /> Esc95320 <br /> Street Number tr city Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) at Laurelwood Lane <br /> SVeet Numbor Street Name <br /> CITY STATE ZIP <br /> Ripon CA 95266 <br /> PHONE#1 T APN# LAND USE APPLICATION Ill?,1 _pb-001DI <br /> (209)613-1611 227-020-13 UnassignedHH <br /> PHONE#2 ExT BO$DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Nancy Rosulek 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 /> 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: �ZDATE: 12- `o\� <br /> PROPERTY/BUSINESS OWNER 13 PERATOR MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IJfAPPL/CANT 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 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 /> TYPEOF SERVICE REQUESTED: Soil Suitability Study Review PAY ENI <br /> COMMENTS: 7 S/fib /•1 _ :�__,,, Q �[Jryt. Yey;—� <br /> lr� rtr — b 4- 30 �, 3� DEC <br /> 7 1� 0 6 - �a t�,,. ,��cy� � Gc� 13 2005 <br /> 61010 I i✓ adAeen'�4'^"'" JO."` SAN JOA <br /> 1 1 + -r, ( JOAQUIN ENVIRONMENTALCOUNTY <br /> HEALTH DEPAME <br /> APPROVED BY: EMPLOYEE#: 3� DATE: �Z S <br /> ASSIGNED TO: EMPLOYEE#: O DATE:'j 12 I. <br /> Date Service Completed (if already completed): SERVICE CODE: S'7fL' P I E: (j <br /> Fee Amount: )10 rA Amount Paid l 0 O Payment Date Z O S <br /> Payment Type ,� Invoice# Check# 2 3 Received By: {y <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />