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SAN JOAQUM*6UNTY ENVIRONN%NTALHEALTH D*14RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SR 6b��-�Z6 <br /> OWNER/OPERATOR M <br /> CHECK II BILLING ADDRESS <br /> Alan Hoffman <br /> FACILITY NAME <br /> Hoffman Property <br /> SITE ADDRESS 30520 E Lone Tree Road Oakdale 95361 <br /> Street Number Dire ioStreet Name Cit Zi Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 9091 North Woodland Drive <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Fre <br /> PHONE#1 ExT� APN# LAND USE APPLICATION# <br /> ( 559 269 2419 229-015-001 & 003 05-240 (MS) <br /> PHONE#2T BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK N BILLING ADDRESS <br /> BUSINESS NAME Nancy Rn,;ijlpk <br /> PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209)369-4228 <br /> CITY STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, 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,STATE and FED L laws. n <br /> y APPLICANT'S SIGNATURE: zgale -� A DATE: <br /> I \ PROPERTY/BUSINESS OWNEREL OPERATOR/ AGER ❑ OTHER AUTHORIZED AGENT 13 <br /> If APPLICANT is not the BILLING PARTY proof ojauthorizadon 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 environmentallsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is�a`v ilab and-at the Same time it i5 <br /> provided to me or my representative. t�V t <br /> TYPE OF SERVICE REQUESTED: Soil Suitability Study Review q p <br /> COMMENTS: A SEp L o <br /> SAN JOAOUIN Ow 2 <br /> OEPARrMENT <br /> t APPROVED BY: �iLrliEl i2� EMPLOYEE#: 3 Zr DATE: Ct ZF CLi <br /> ASSIGNED TO- v'-/U P q n/,C— EMPLOYEE M Q.�p�j CJ DATE: ?12SQS <br /> Date Service Completed (ff already completed): SERVICE CODE: -5-22- PIE: 2— <br /> Fee Amount: Do Amount Paid te <br /> Payment Type Invoice# Check# 13o2-, Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />