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SAN JOAQUI111100, OUNTY ENVIRONMENTAL HEALTH.',.,'ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> La) <br /> OWNER/OPERATOR Arnaudo Brothers Inc. (Greg Arnaudo) CHECK H BILLING ADDRESSO <br /> FACILITY NAME Arnaudo Brothers Property <br /> SITE ADDRESS 13161 S. Jack Tone Rd. Stockton 95215 <br /> Street Number I Direction Street Name city I Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 13193 S. Highway 33 <br /> Street Number Street Name <br /> CITY Santa Nella STATE CA Zip 95322 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 826-1717 01-140-09, 10, 11, 12, 13, 14 LA-01-105 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> Neil O. Anderson & Associates Inc. 1209 1 367-3701 <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 /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all RJQttS2 � <br /> COUNTY Ordinance Codes,Stand ardsSAATAA��TTE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: /?j Neil O.Anderson&Associates.Inc. DATE <br /> i� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT 0{o/ Consultant OUNT' <br /> IN CTAL <br /> IfAPPLICA,VT is not the BILLING PARTY proof of authorization to sign is required Titre ENVIRONPAPRTMENT <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the propertytlFBAtvQ�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: t <br /> CoMNENrs: Please review the attached Soil Suitability/ l4itrate Loading tudy. The report review fee <br /> of$465 is attached. If you have any questions, please do not hesitate to call. Abby <br /> �� /-" <br /> � <br /> U — <br /> AEI41OVIED BY: EMPLOYEE M DTE: D <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): f . SE �i� <br /> RVk0O E: ZZ P/E: � <br /> Fee Amount: " '� (,J L`j-7 <br /> Amount Paid Payment Date 3 0 <br /> Lf <br /> Payment Type ✓t s Invoice# Check# ll-361 4,65 Received By: <br /> y <br /> EHD 25 /� . SERVICE REQUEST FORM <br /> REVISEDSED&-ES-02 //��'�'•�_uef/ <br />