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ex:s <br /> SAN JOAQUIN COUNTY ENVI-L-ONM:ENTALliEALTH.DEPAR'FM.ENT <br /> SERVI REQUEST <br /> Type of Business or Property FACILITY iD# SERVICE REQUEST# <br />` OWNER I OPERATOR CHECK If BILLING ADDRESS® <br /> David Silva <br /> FACILITY NAME Silva Trucking <br /> SITE ADDRESS 8863 S anthey Road French Camp �3 Zi p3 Code <br /> Street Number Direction Street Name Cit <br /> _ HOME or MAILING ADDRESS (If Different from Site Address) <br /> y( j19 1 <br /> Street Number Street Name <br /> j /�STATE ZIP 3 '3 1 <br /> L <br /> r <br /> CITY lzrc Nc kI C s9 I"P C41. ! J <br /> PHONE#t ExT• APN# LAND Use APPLICATION# <br /> t209 ) 982-1114 193-200-06 PA-07-439 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR Nancy Rosulek Kramer CHECK It BILLING ADDRESS❑ <br /> PHONE# Exr' <br /> BUSINESS NAME <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209 )369-4228 <br /> A 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 t at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST and F EH.AL is <br /> APPLICANT'S SIGNATURE: DATE: i:I <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARproof 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 tine it is <br /> provided to me or my representative. ! 1 �� <br /> 61 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: `LL3 �''� <br /> z f Z(f° h <br /> i)'`'`t, il'. .��i/A'l� "� A-3 1 I Y� SPN�0 Np�QA <br /> N <br /> APPRO�EBIY: EMPLOYEE#: DATE: <br /> ASSIGNEMPLOYEE i#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: D� Amount Paid R 4 D ,-D C) Payment Date [ 0-7 <br /> Payment Type Invoice# Received By: <br /> SERVICE REQUEST FORM <br /> EHD 48-01-025 <br /> REVISED 6-5-02 <br />