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SAN,IOAQU.raw ../ 'ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Mr David Skodmore CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Van De Pol Pro ert <br /> SITE ADDRESS 28567 E State Route 120 Escalon 95320 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4206 Technology Drive <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Modesto _CA 95356 <br /> PHONE#1 Ext. APN# LAND LISE APPLICATION# <br /> ( ) 229-170-37 PA-03-602 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> Dave Welch <br /> BUSINESS NAME PHONE# EXT. <br /> Neal 0- Anderson and Assocoates, Inc- ( 209)367-3701 <br /> HOME Or MAILING ADDRESS FAX# <br /> 902 Industrial Way ( 209)369-4228 <br /> CITY STATE ZIP <br /> Lodi <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 /> 1 also certify that I have prepared t li ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand rds, E and F D L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGiER OTHER AUTHORIZED AGENT 5 L I 9 �L-y _ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <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 /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN"r 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: ->'9' <br /> COMMENTS: Please expedite the review of the following Soil Suitability Study & attacV=�9�9;4- <br /> t$ ed <br /> January 18, 2005. Incl o ed is the expedite review fee of $372. If you haOns <br /> please call. <br /> Dave 2 <br /> JAN <br /> 4 Z005 <br /> U <br /> BY: -A�- � EMPLOYEE#: l SAN @�. IN KIAA-C <br /> o� 1 G� �G� M i�flPlu�T E�1k U <br /> ASSIGNED TO: f F–Yw A- EMPLOYEE#: <br /> Date Service Completed (if already completed): SERVICE CODE: \ P I E: (� p <br /> Fee Amount: Amount Paid ' Payment—Date <br /> Payment Type ✓ Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />