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SAN JOAQUIN COUNTY ENVIIIESNMENTALHEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR Steve Stoffel <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 11345 & 1131 E. Jahant Road Acampo 95220 <br /> Street Number Direction Street 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 Eltr' APN# LAND USE APPLICATION# <br /> ( 209) 663-7594 007-150-13 <br /> PHONE#2 BOIS DISTRICT <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Tina Cheney <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME - PHONE# Ex . <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 /> 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 ATE and FED L 1 / <br /> APPLICANT'S SIGNATURE: arST o.,Lj B //!� /�QZZAj/N6 <br /> L- DATE: �r '/5'O( <br /> PROPERTY/BUIRNESS OWNER R OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTr 5W1,Iiee,- <br /> IfAPPLICANT is not the BiLLTNG PARTY proof of authorization to sign is required VTitle <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 time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Pq <br /> COMMENTS: C0,2 VC-D <br /> ljl}y9�-r-�?Q -�i 7 t7� JUN .{ [ <br /> I f �(J i ` ` l / of m(in.`�L �'K�v/lc.J ��1�/� SANJ I J 2006 <br /> I`11 1 g 9 �`�� - -�T''r+'JrtN ENVOIRO UI N COUA,IY <br /> HEALTH NMENIAL <br /> APPROVED BY: EMPLOYEE#: DATE: IMEIV <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (i(already completed): SERVICE CODE: �� P 1 E <br /> Fee Amount: Amount Paid , . (Sp Payment Date <br /> o r> <br /> Payment Type L.-' Invoice# Check# 32- (. ' ; Received By: �� C{ <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />