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T <br /> SAN JOAQUIN COUNTY ENVIRONIPIAEN`t4,1,HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 10# SERVICE REQUEST# <br /> ��eoo�z8�4 <br /> OWNERIOPERATOR <br /> Mr- Lnqnrao CHECK If BILLING ADDRESS O <br /> FACILITY NAME <br /> Diede Construction <br /> SITE ADDRESS 12400 N Highway 99 Frontaqe Lodi 95240 <br /> Street Number rection Street Name Ci2 Code <br /> HOME or MAILING ADDRESS Ilf Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# <br /> tJs,ND USE APPLICATION# <br /> 058-110-48 & 50 PA-05-3681367 <br /> PHONE#2 ExT. BOS DISTRICT 'LOCATION CODE <br /> f ( } <br /> t <br />` <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> Rr=auEsroR <br /> CHECK If BILLING ADDRESS <br /> Nancy Rn-,uh-k <br /> BUSINESS NAME PHONE# Exr. <br /> Neal 0- Ant-4-i-son and Associates, Iric— (209)'167-3701 <br /> HONE or MAILING ADDRESS FAX# <br /> 209 369-4228 (209)369-4228 <br /> CITY Lodi STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: ll, 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 1 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• 2 <br /> PROPERTY/BUSINESS OWNER❑ PERATOR I MANAGE ❑ OTHER AUTHORIZED AGENT® Cans Ultant <br /> IfAPPLICANT 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. <br /> TYPE OF SERVICE REQUESTED: Soil Suitability Study/ Nitrate Loading Stuffy Review � t <br /> COMMENTS: <br /> 7/000- JUN 2 7 zoo, <br /> SAN JpAQUlN <br /> COUN7y <br /> ENVIfilON <br /> TAIM. <br /> APPROVED BY: EMPLOYEE#: DATE: 27 Q <br /> 6Lt Ur O� <br /> ASSIGNED TO: d-�ic—to E M1 j h EMPLOYEE#: 5 3(o�j DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z,S P I E: <br /> Fee Amount: �S p Amount Paid Payment Date r?•b <br /> Paymen#Type Invoice# Check# Recelved By: I� <br /> i <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />