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SAN JOAQ1sw( COUNTY ENVIRONMENTAL HEALI� DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR Traylor Shea Precast CHECK if BILLING ADDRESSE] <br /> FACILITY NAME Traylor Shea Precast <br /> SITE ADDRESS 3836 1 N I Newton Rd. Stockton 95205 <br /> Street Number Direction Street Name city zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6205 E. Avenue T <br /> Street Number Street Name <br /> CITY Littlerock STATE CA zip 93543 <br /> PHONE#1 APNN JB <br /> D USE APPLICATION# <br /> (703)999-5523 132-060-02 A-'07-438 <br /> PHONE#2T S DISTRICT LOCATION CQDE' <br /> Z �- t> <br /> l ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME <br /> Neil O. Anderson & Associates PHONE#Inc. 209 367-3701 <br /> FAx# <br /> HOME Or MAILING ADDRESS <br /> 902 Industrial Way (209)369-4228 <br /> CITY Lodi STATE CA 'JP <br /> 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 ENVfRoNMENTAL 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: (is, /4- (--_ DATE: i1 - <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER M OTTER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the Brcc/NGPAxzr proof of authorization to sign is required Trete <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 the,H6nOd"e it is <br /> provided to me or my representative. `( -G <br /> TYPE OF SERVICE REQUESTED: Review of Soil Suitability/Nitrate Loading Study <br /> COMttENrB: rt/io/p� <br /> t//0(4 I f51"7, D <br /> "PGr1 t�Ct/lt?/�� rSe,•) zavv I (.S) 3 a � SAN JOAGIUW C� Ti <br /> ENVIiR <br /> 49F t`«el M t gTr7 HEALTH DEPAPONMETMEtJT <br /> .. <br /> APPROVED BY: EMPLOYEE#: L"J �, �.-/ DATE: / <br /> - � ;� - <br /> a EMPLOYEE# r/Tye r„ ' DATE: f <br /> ASSIGNED r0: k- :, C r 77; <br /> Date Service Completed (if already comploted): SERVICE CODE: PIE' <br /> Fee Amount: -t! 4r, r; Amoc Paid ly,'-"i Payment Date L r <br /> Payment Type Invoice# check.# Received By <br /> SERVICE REQUEST FORM <br /> EHD 48-01-025 <br /> REVISED 6-5-02 <br />