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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVIEST# <br /> OWNER/OPERATOR <br /> CHECK II BILLING ADDRESS <br /> FACILITY NAME <br /> Bacchetti & Grewal Pro a SW Corner Bird and Lovelyl <br /> SITE ADDRESS 4700W Lovelv Road Tracy 95304 <br /> Street Number DI 60n Street Name I I Decade <br /> NOME Or MAILING ADDRESS (if Different from Site Address) 19930 South MacArthur Drive <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Tracv CA 95304 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> I ) 1250-100-08. -09. -10 PA- 05-522 (LA) <br /> PHONE#2 Exr. BOS DISTRICT LO:.ATIDN CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Nancy Rosulek <br /> CHECK If BILLING ADDRESS 0 <br /> BUSINESS NAME PHONE# Elrr. <br /> Neil O. Anderson & Associates <br /> HOME or MAILING ADDRESS FAx# <br /> 209 369-4228 (209)369-4228 <br /> CITY Lodw <br /> STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of some, <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER[3 OPE TOR/MANAGER <br /> OTHER AUTHORIZED AGENT[3 <br /> IfAPPL1CAVT is not the B76LING PARTY prop 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 enviromnental/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. <br /> TIDE OF SERVICE REQUESTED: Soil uitability Study RECEIVED <br /> COMMENTS: JAN 2 0 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: EMPLOYEE#: DATE: Z6 <br /> ASSIGNED TO: EMPLOYEE#: V DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ZZ <br /> Fee Amount: $ I d�6' Amount Paid \ 'i� (p , OO Payment Date <br /> PaymentType ✓ Invoice# Check# �� 2 ` Received By: �I <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />