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SAN JOAQUATOUNTY ENVIRO-I MENTAL HEALTH LEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 ti o S OD <br /> OWNER/OPERATOR <br /> Mr. Lowell Rathe CHECK KBILLING AODRESSO <br /> FACILITY NAME Rathe Property <br /> Site ADDRESS 22530 1 E. Liberty Road Clements <br /> SUvot Number Di---flon I Cf T <br /> HOME Or MAILING ADDRESS (If Different from Site Address) FsECEIV <br /> Street Number treat Name <br /> CITY STATE ZIP DEC — 1 004 <br /> PHONE#1 ElT. APN# LAND USE APPLICATION# SAN JOAQUIN G UNTY <br /> ( I 021-200-22 PA-04-363 ENVIRONMEr TAL <br /> PHONE#1 Ell. BOS DISTRICT LOC ODE MENT <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR David Welch CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ' <br /> Neil O. Anderson & Associates Inc. 1209 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 a lication and that the work to be performed will be done in accordance with all SAN JOAQUrN <br /> COUNTY Ordinance Codes,Stan 7)�,ST T^and 1'EDE�laws. <br /> APPLICANT'S SIGNATU DATE: <br /> IV(/ y '1.1UTA(IIIA\ _ <br /> PROPERTY/BU Si NESS OWNER 171 'OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Consultant <br /> If APPLICANT is not the BILLING PARTY proof of authorization f0 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 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: r�y4I2.-I p <br /> COMMENTS: <br /> Please review the attached SSS/NLS. The expedited report review fee of$697.50 (465 *1.5) <br /> is attached. If you have any glLestio please do not hesitate <br /> to call. =of/� Oi � '� <br /> APPROVED BY: EMPLOYEE#: DATE: 2, <br /> ASSIGNED TO: EMPLOYEE#: Ulf DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: 2 PIE: <br /> Fee Amount: 7. -5Z Amount Paid-$ 97 SD Payment Date 11 I D <br /> Payment Type Invoice# Check# Received By:t <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />