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a <br /> SAN JOAQUIM;OUN7TY IENV IRONMENTAL HEALTH blbARTM;.N I <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5/l Oo4z��3 <br /> OWNER/OPERATOR <br /> CHECK H BILLING ADDRESSMr- Mike Modporo-c; � <br /> FACILITY NAME <br /> Mideiros Property <br /> SITE ADDRESS 23250 N Sowles Road Acampo 95220 <br /> Street Number Street Name Cift Zip <br /> HOME or MAILING ADDRESS (if Different from She Address) P.O. Box 763 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Folsom CA 95763 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (cl 16) Cl gg_ Yo YO 007-380-14 PA-04-393 <br /> PHONE#2 2 En. BOS DISTRICT LOCATION CODE <br /> M 10 3qa- y41VO <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Dave VVPIrh <br /> BUSINESS NAME PHONE# Em <br /> )167-3701 <br /> HOME Or MAILING ADDRESS FAX# <br /> 902 Industrial (209)369-4228 <br /> CITY Lorin STATE CA ZIP 95240 <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> / l / / Q/d� DATE: TUh P. 3-'2605- <br /> PROPERTY/BUSINESS OWNERIrLJ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> If APPLICANT is not the BILLING PARTY proof of authorization f0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 envirollmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it i5 <br /> provided to me or my representative. <br /> 710 EHT- <br /> TYPE OF SERVICE REQUESTED: Soil Suitability Study Review CEIVED <br /> COMMENTS: �7` 5-- x-, 5 / <br /> ../ JUN 6 2005 <br /> J•r� SAN JOAQUIN COUNTY <br /> �2 ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: V' LI 1J F-40--A EMPLOYEE#: o 3 Zq DATE: <br /> ASSIGNED TO: M6 4J /,-A EMPLOYEE#: 3-'3 & lQ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S-�L P1E:a&,O <br /> Fee Amount: i -� CJ Amount Paid — Payment Date O <br /> Payment Type Invoice# Check# R ceive By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />