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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> John Trinkle CHECK If BILLING ADDRESS LdW <br /> FACILITY NAME <br /> SITE ADDR 458 5001 S. Kasson Road Tracy 95304 <br /> t Nambar I Direction Street Name I no Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 24551 Kasson Road <br /> Street Number Street Name <br /> CITY Tracy STATE ZIP <br /> PHONE#1 Ear. APN# LAND USE APPLICATION# <br /> (209 ) 610-2449 239-110-15 & 239-180-05 <br /> PHONE#2 Ear. BOS DISTRICT LOCATION CODE <br /> C <br /> CONTRACTOR/ SERVICE REQUESTOR L <br /> REQUESTOR Tina Cheney CHECK If BILLING ADDRESS v\I <br /> BUSINESS NAMEPHONE# ' <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209 )369-4228 7[ <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 J <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 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,STPTE and FEDERAL laws. p <br /> APPLICANT'S SIGNATU ` DATE: <br /> V <br /> PROPERTY/BUSINESS OWNER OPERATOR I MANAGER 13 OTHER AUTHORIZED AGENT❑ <br /> I,jAPPLICANT is not the BILLING PAR lY proof 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 t0 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. /1 n <br /> TYPE OF SERVICE EOUESTED: �`�,f_Fi�C-,� �L.�_a S'Lt.,-1-,4 CC-- 7-A-� IrJAL-770' J /Q b Z <br /> COMMENTS: A �,y, HAYMENT <br /> RECEIVED <br /> �f�l �d8 OCT 10 2007 <br /> r� �qq SAN JOAQUIN COUNTY <br /> APPROVED BY: L L V E L P�--/L EMPLOYEE#: 0�2i DATt1EAL7 A1E'NT <br /> V <br /> ASSIGNED TO: '—r-Af 10 P O u L�-c EMPLOYEE#: t(-04_S' DATE: /U <br /> Date Service Completed (N already completed): SERVICE CODE: <3 tS P I E:2_6o_3 <br /> Fee Amount: 15&-L;a Amount Paid 1 q Payment Date t 'J 101 6 -7 <br /> Payment Type t_/ Invoice# Check# -L -L2— Received By: 0 ('-. <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />