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SAN JOAQLSWCOUNTY ENVIRONMENTAL HFALT1140EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> Mr John ';.qndhnp <br /> FACILITY NAME <br /> Time Oil Pr ert <br /> SrEAoDREss 13475 N Jack Tone Road Lodi 95240 <br /> Street Number irection treet Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 W. APNIt LAND USE APPLICATION# <br /> ( ) 1 063-260-04 Unassigned <br /> PHONE#2 Exr' BOS DISTRICT LOCATION CODE <br /> 1 ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR CHECK if BILLING ADDRESS <br /> nave Welch <br /> BUSINESS NAME PHONE# Exr' <br /> HOME Or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209)369-4228 <br /> CITY <br /> 1 6 - <br /> CITY LodSTATE 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,Sta r TATE and FEDERAL laws. 1 <br /> APPLICANT'S SIGNATUpJI%( �.�I� DATE: O J� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Consultant <br /> ffAPPLicANT is not the B!L/✓NG 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 /> TYPE OF SERVICE REQUESTED: Nitrate Loading Study Review C)MI) �((P-cn � I�VA _/ doAA.t <br /> COMMENTS: <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 5-�. P 1 E:49OZ <br /> Fee Amount: t�s, of) Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> 1 <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />