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` "omnl /y, <br /> SAN.jOAQUI OUNTY ENVIRONMENTAj..HEALTH WPARTMENT <br /> SERVICE IfE REST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 9�2(N351 <br /> OWNER/OPERATOR <br /> I CHECK If BILLING ADDRESS <br /> Randall Lange <br /> r FACILITY NAME <br /> SITE ADDRESS ERZ Jahant Road Acampo 95220 <br />` Strleet Number Direction Street Name Ci i God* <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> f Street Number Street Name <br />{ CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br />+ ( I 003-150-08 PA-0500424 (pending) M <br /> I PHONE#2 Err. BOS DISTRICT LOCATI ODE <br /> ( 1 <br /> t <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS© <br /> Dave WelCh <br />'i BUSINESS NAME PHONE# ExT• <br /> Neil 0- Anderson and Associates, Inc. (209)36 7-3701 <br /> HOMEorMAILINGADDRESS FAX# <br /> 902 Industrial Way (2 09) -422 <br /> CITY LodL STATE CIA ZIP " <br /> 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 FNVJRONMFNTAL 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 a plication and that the work to be performed will be done in accordance with all SAN JOAQUTIv <br /> r' COUNTY Ordinance Codes,Stan scs,,STA FEDERAL laws. <br /> I �- <br /> APPLICANT'S SIGNATU DATE: w �[v <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGE C Lr1Su � 0 V%T <br /> I APPLICANT is not the BILLING PAR71,proof o authorization to sign is required Title <br /> f P ll <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 /> C information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avail , at ' me time it is <br /> provided to me or my representative. IRRE T,F—V ED <br /> TYPE OF SERVICE REQUESTED:Soil Suitability and Nitrate Loading Study Review 1_` ._ 15 i995 <br /> COMMENTS: /� //F �Q� AlJ <br /> ,IDAQUIN COUNIRONM_NTAL i <br /> ENV <br /> NDEPARTMENT <br /> APPROVED BY: EMPLOYEE#: DATE: !� O <br /> ASSIGNED TO: t EMPLOYEE#: � DATE: r <br /> Date Service Cpmpleted (if already completed): SERVICE CODE: 2-5-113 1 E: 2-6D2— <br /> Fee Amount: Amount Paid Cb Payment Date <br /> Payment Type Invoice# Check# �3 S Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />