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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS r• <br /> FACILITY NAME <br /> Aziz Pro ert <br /> SITE ADDRESS z�3oi S Reeve Road Tracy 95304 <br /> Street Number Direction <br /> Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> AK AROWS-a Street Number Street Name <br /> STATE ZIP <br /> CITY <br /> Exr. APN# LAND USE APPLICATION# <br /> PHONE#1 <br /> (209)832 5867 209-180-02 PA-05-470 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILL .G ADDRESS <br /> Nancy Rosult-k PHONE# EXT. <br /> BUSINESS NAME Neil 0- Anderson and Assoriates, Inr ( 209)36Z-3701 <br /> HOME Or MAILING ADDRESS FAX# <br /> 902 Industrial Way ( 209)369-4228 <br /> CITY STATE CA ZIP <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 /> 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 anA-F-E-DERQ,L laws. <br /> APPLICANT'S SIGNATURE: �/ � t DATE: Oy ` <br /> L PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Soil Suitability Study/,Nitrate Loading StudyVED <br /> COMMENTS: � �� �?>�� <br /> APR 12 2006 <br /> �I <br /> SAN JOAQUIN COUNT( <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: t J EMPLOYEE DATE: It <br /> ASSIGNED TO: �1 EMPLOYEE#: 0 v DATE: <br /> T1 1 <br /> Date Service Completed (if already completed): SERVICE CODE: �� P/E: � <br /> Fee Amount: S u7- Amount Paid j 4 tos ()Q Payment Date L.f O <br /> Payment Type ✓, Invoice# Check# Z� Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />