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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2� <br /> OWNER I OPERATOR BILLING PARTY 0 <br /> Daniel Lowry c/o D 'ede Construction <br /> FACILITY NAME <br /> SA-01-4 Aspire School <br /> SPIE ADDRESS <br /> 11492N@r,th Highway 99 East Frontage Road <br /> Strat Number ectan street Name Type Sutte t <br /> Mailing Address (If Different from Site Address) <br /> P.O. Box 1007 <br /> CITY Woodbridge STATE CA ZIP 95258 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DIsTRICr LocATIoN CODE <br /> ( ) ------ -- I <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUC•STOR BILLING PARTY 0 <br /> Cecil Dillon <br /> BUSINESS NAm Fillon & Murphy PHONE# EXT. <br /> 09) 334-6613 <br /> MAILING ADDRESS FAX# <br /> F.O. Box 2180 4_ <br /> CITY Lodi STATE CA ZIP 5241 <br /> I <br /> \ <br /> Bit-LING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that an site and/or project Specific <br /> PUOUc HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION hourly charges associated with this project or activity will be bill 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 JOAQU:N COUNTY Ordinance Codes,Standards.STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: �/ Cecil Dillon DATE: 4/20/01 <br /> PROPERTY/BUSINESS OWNER O c OPERATOR/WNAGER Cik OTHER AUTHORIZED AGENT O Engineer <br /> IfAPPLIc.wr is not tlm Bu�+G P�ary proof of authoriz2don to sign Is mquiivd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentaftle assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVtRONME4TAL HEALTH DIVISION as Soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> �GMh1EhiS: <br /> This fee is to review the Soil Suitability/Nitrate Loading Study <br /> for SA-01-4 . If you need additional information please contact <br /> Cecil Dillon at (209) 334-6613 . <br /> INSPECTORS SIGNATURE: CONTRACTOR/S SIGNATURE: <br /> APPROVED BY:. q� EMPLOYEE#: G C' DATE: Z -7 G <br /> ASSIGNED TO: EMPLOYEE#: `f( J DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �'� P/E: 24,0 Z <br /> Fee Amount: Amount Paid 5 b Payment Date 4f _ <br /> 'aymcnt Type Invoice# Check#G eceived By: <br /> 1 <br />