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C � <br /> SAN.IOAQUI1 rOUNTY ENV IRON MENTAL HEALTH h6ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR v <br /> CHECK If BILLING ADDRESS X <br /> Mr. Dan Tahar <br /> FACILITY NAME <br /> Nunhems USA Inc. <br /> SITE ADDRESS 7087 E Peltier Road Acampo 95220 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT APN# LAND USE APPLICATION# �� /✓� �/�� <br /> (0)-M-11 005-260-41 Unassigned CNXJ l/ <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> 0N) 17 ) ��A /Z <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Nancy R. Kramer <br /> BUSINESS NAME PHONE# EXT. <br /> Neil 0- Anderson and Associates- Inc- ( 209)367-3701 <br /> HOME Or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209) 69-4228 <br /> CITY Lodi 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: -7/ <br /> -41 DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENTE3 <br /> If APPLICANT is not the BILLING PARTY,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 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. J,A- t <br /> TYPE OF SERVICE REQUESTED: Soil Suitability Study & Nitrate Loading Study Di <br /> COMMENTS: �/ n �� �� o Y -I/t f <br /> 0 2 2006 <br /> -7 D Cc, ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE-?L— <br /> Fee Amount: Amount Paid $ q-(oS �� Payment Date g� <br /> Payment Type ✓ Invoice# Check# Q (�g S�3S( Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />