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SAN JOAQtt'(COUNTYENVIRONMENTAL HEALTH7?$PARTMENT ' <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR Mr. Mike Terpstra <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Terpstra Property <br /> SITE ADDRESS 26222 E. Mahon Ave. Escalon 95320 <br /> Street Numbb I Diredt I V M Name CItV Me Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 455 Laurelwood Lane <br /> Street Number Street N,.. <br /> CITY <br /> Ripon CA 95266 95266 <br /> PHONE#1 Ems' APN# LAND USE APPUcATON# <br /> ( 209)613-1611 227-020-13 Unassigned <br /> PHONE#2 Exr. [301S <br /> plSTgy;T LOCATI NCODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco <br /> CHECK N BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> Neil O. Anderson & Associates 11 C. 209 l 367-3701 <br /> HOME Or MAILING ADDRESS FAX# <br /> 902 Industrial Way 12091369-4228 <br /> CITY Lodi 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 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: n„ )2,,v/A/, ().At/&,W4-1J-'sC DATE: 316 <br /> PROPERTY/BUSINESS OWNER❑ OP TOR/MANAGER ❑ OTHER AUTHORIZED AGENT P,P <br /> IfAPPLICANT 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 environmentaVsite 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: j/���Ac C- S�(.L S Lt-�—F G Cry'JT <br /> COMMENTS: 3, /510 6 R lv'®,•y�.,,, PARE CEIVED <br /> 4716(e Ndd % 3 20 5 <br /> 76OUW COUNT( <br /> IW SAN JOA ENTAL <br /> APPROVED BY: LL ��� EMPLOYEE#: p`3�I DATEH tRJ= <br /> ASSIGNED TO: V4-Al 10t/ N£ EMPLOYEE#: t(-Oa-b DATE: <br /> Date Service Completed (if already completed): SERVICE CODE:3 cs� P I E <br /> Fee Amount: 's/o Amount Paid -6 -0 Payment Date t l y3 US <br /> Payment Type Invoice# Check# I Received By: �7 L <br /> E 48-01-025 SERVICE REQUEST FORM <br /> RE D 6-5-02 <br />