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SAN JOAQUI-- BOUNTY ENVIRONMENTAL HEALTY 'NEPARTMENT <br /> �ftwe SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR grad Klump CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME Klump Property <br /> SITE ADDRESS95320 <br /> 17201 S' Seidner Road Escalon <br /> Street Number Direction Street Name cityZi cone <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ear. APN# LAND USE APPLICATION# <br /> (209)838-7049 229-160-15 Unassigned <br /> PHONE#I En. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR Abby Racco CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# ' <br /> Neil O. Anderson &Associates Inc. 209 367-3701 <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 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 ERAL laws. <br /> APPLICANT'S SIGNATURE: Neil O.Anderson&Associates,Inc. DATE' to I -/0 <br /> PROPERTY/BUSINESS OWNER[] OPERA OR/MANAGER ❑ OTHER AUTHORIZED AGENT® Consultant <br /> IrAPPL/CANT is not the B/LL/NG 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: 1t.,lhZ'fA('� '��A�p ,/�rD—eP l®JLTBI n"` ( EN <br /> COMMENTS: (L/ti/e� FtE <br /> QCT 2 8 2005 <br /> ,t <br /> ��OT ��� S�NVIRONME MEPIT <br /> TN DEPAP <br /> APPROVED BY: 0(- I EMPLOYEE#: 032_/ DATE: <br /> ASSIGNED TO: VQ ot ry EMPLOYEE#: Q�/�( DATE: <br /> Date Service Completed (if already completed: SERVICE CODE: 3 PIE: <br /> z <br /> Fee Amount: ��, Amount Paid , O b OD Payment Date <br /> Payment Type ✓ Invoice# Check# 1 %C� 1 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />