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41SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 'e <br /> SEWtckaEQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GHu"GLH .- - - _ 5W-00clS () 3 n <br /> jOWNER I OPERATOR <br /> Mark Butler CHECK if BILLING ADDRESS® <br /> FACILITY NAME Harvest Bible Church <br /> SITE ADDRESS 11130 Nection Highway 99�reet tEast Frontage Lodi zI Code <br /> Street Number Dir <br /> HOME or MAILING ADDRESS (If Different from Site Address) 10088 North Hwy 99 <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP <br /> PHONE#1T• APN# LAND USE APPLICATION <br /> (209) 9;:51 '94_ 059-260-58 PA-06-287 <br /> PHONE#Z ExT B05 DISTRICT LOCATION CODE <br /> (Z09) 3(oy( - Q29 Ca <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQtI ESTOR r <br /> Nancy R. Kramer CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# E'ff' <br /> Neil 4. Anderson & Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FAx# 1 <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, I <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 applicatia and that the work to ormed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar T C� / <br /> APPLICANT'S SIGNATURE: DATE: 8ZI <br /> "PROPERTY/BUSINESS OWNER❑ OPEC ATOR/MANACER ❑ OTHER UTHORIZED AGENT 0 AF-G H I T e e_,�"t - --- ~v <br /> If APPLICANT is not the BILL fNG PARTY proof of autlorizationj to Sigh is required Title <br /> AUTHORIZATION TO RELEASE IN ORMATION: 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 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: SOII Suitability/ Nitrate Loading Study <br /> COMMENTS: 0�Z� �U l7I � v ZOOS <br /> SAN a/-f .�SCG� EWVIRQEPARTMt"NY <br /> ldgir�i�� HEAL_-TH+ <br /> 1 <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid ..r^ . Payment Date <br /> Payment Type Invoice# Check# l4eceived By' <br /> s i <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br /> '.t <br />