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, Y <br /> SAN JOAQU*I(COUNTY ENVIRONMENTALIIEALTHZItPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SKbo 44-7 (DIA <br /> OWNER/OPERATOR Ted Green <br /> CHECK N BILLING ADDRESS <br /> FACILITY NAME Pace Supply <br /> SITE ADDRESS 4015 Newton Road Stockton <br /> Street Number tName cft C940 <br /> HOME or MAILING ADDRESS (if Different from Site Address) 2815 Duke Court <br /> Street Number tree[Name <br /> CITY Santa Rosa STATE CA ZIP 95407 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> I ) 1 132-070-06 -PA-C) <br /> PHONE#2 E[r. BOS DISTRICT LOCATIO C DE <br /> ( ) , 2 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Nancy Rosulek <br /> CHECK It BILLING ADDRESS <br /> BUSINESS NAME PHONE# E'o' <br /> Neil O. Anderson 8t Associates Inc. 1209 367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209 )369-4228 <br /> CITY Lodi STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of some, <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 /> 1 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: DATE: /11q— 6 <br /> PROPERTY/BUSINESS OWNER 13 DS <br /> OPERATOR/MANAGER 13 OTHER AUTHORED AGENT® /jj� <br /> IjAPPLICANT is not the BILLING PARTY,Proof of allthOriZatiOn 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 t0 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. �6 y p <br /> TYPE OF SERVICE REQUESTED: SOH Suitability / Nitrate Loading Study /t' <br /> COMMENTS: (p/7�/� ��/a�Ok. ' <br /> 14 zooe <br /> /2�fYJl7s , jJ/a.,1ts+ SAN 10AQU <br /> M.L- C5Cc7�o HES H p AIMEAITgL <br /> (so � EPgq�E <br /> APPROVED BY MPLOYEE#: DATE: / <br /> ASSIGNED TO: / EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: A'j 2 PIE: 2� <br /> Fee Amount: 4157 Amount Paid N b s, CU Payment Date b I y <br /> Payment Type `.. Invoice# Check# Z Received By: tv �/ <br /> EHD 4"1-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />