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l <br /> SAN JOAQ I,v COUNTY ENVIRONMENTAL HEALTI�`PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Agricultural <br /> OWNER i OPERATOR <br /> Judith Marek and Jo Anne Edward (Zottarelli Ranch Partnership) CHECK if BILLING ADDRESS <br /> FACILITY NAME Zottarelli Ranch <br /> SITE ADORE <br /> %039 & 13101 S.. St. Rt. 99 W. Frontage Rd. TManteca 95336 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 13101 S. St. Rt. 99 W. Frontage Rd. <br /> Street Number Street Name <br /> CITY Manteca STATE CA "' 95336 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 823-0110 204-050-44 and -29 Unassigned CJ <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> (209 1 823-6743 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Abby Racco <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ei. <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME Or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209 )333-8303 <br /> CITY Lodi STATE CA z'P 95240 <br /> BILLING ACKNOWLEDGEMENT: I, 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 S TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Neil O.Anderson&Associates,Inc. <br /> DATE <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Consultant <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 sae�tuu�;t is <br /> IV- <br /> provided to me or my representative. ��� J,--ii - <br /> J <br /> TYPE OF SERVICE REQUESTED: 4-f t ,C E E <br /> LL . A C ZE C O.'�J 1 QO <br /> COMMENTS: Please review the attached Surface/Subsurface Contamination Report. SEP 2 <br /> If you have any questions, please do not hesitate to call. SAN JOAQUIN COUN-iy <br /> Abby ENVIRONMENTAL <br /> �p y HEALTH DEPARTME T <br /> APPROVED BY: C9 U�t�� t EMPLOYEE#: jz DATE: !a ZK G <br /> ASSIGNED TO: SS t EMPLOYEE#: ((4S'L, DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3 i� P/E: zL C 3 <br /> Fee Amount: l gic' UCS Amount Paid (g�,v Payment Date Q a q <br /> Payment Type Invoice# Check# (oS (�� Received By: z <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />