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SAN JOAQUAwCOUNTY ENVti1 OMJENTAL HEALTH*,�JEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQ EST# <br /> :L S2oo4r(olo5- <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Ms- Judith Marp-k Zotarellffi Ranch Partnership <br /> FACILITY NAME <br /> Zottarelli Ranch Pro ert <br /> SITE ADDRESS 13039 & 13101 S Highway 99, West Frontage Road Manteca 95336 <br /> Street Number I Direction I Street Name city Zio 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 /> ( ) 204-050-44 & 204-050-29 PA-04-623 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS X <br /> Dave Welch <br /> BUSINESS NAME PHONE# EXT' <br /> Neil 0- Andpirson and Associates, Inc- onq)367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209)369-42 8 <br /> CITY Lode <br /> 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 ap lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar ,ST TE and FEDERAL laws. ( r <br /> APPLICANT'S SIGNATURE DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Consultant <br /> I(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 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 Review <br /> COMMENTS: Please review the following Soil Suitability Study. We have attached the service rev +Y \11`C <br /> of$186. If you have any questions please call. <br /> Dave �r.�►1 �fl►� ��lzl os - �2e�oo�t MAS 2 5 005 <br /> t� tom. <br /> ✓"� r"�" i7 - ` jC7tv�c !EjAN JOAQUIN C TALTM <br /> APPROVED BY: EMPLOYEE#: DATE: MENT <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Complet d (if already COT ted): SERVICE CODE: 2 7 P I E: MQ/ <br /> Fee Amount: d Amount Paid Payment Date -t <br /> Payment Type Invoice# Check# -1 -�"-j Received By: <br /> 54 <br /> SERVICE REQUEST FORM <br /> RHD 025 <br /> REVISED SED 6 6-5-02 �� <br />