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SAN.IOAQUi-,COUNTY ENVIRONMEP-TAL HEALTH MPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Hammer Truck*nq, Inc. C/O Ms- Wendy Stafford <br /> FACILITY NAME <br /> Hammer Truckin Inc. <br /> SITE ADDRESS 6318 E State Route 12 Lodi 95240 <br /> Street Number Direction Street Name Cit 2i Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 2046 Petersburg Way <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Lodi CA 95240 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( ) 049-120-03 PA-04-1 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Dqvp Welch <br /> BUSINESS NAME PHONE# EXT' <br /> Npml 0- Anderson and Assnraatps, Inr- (209)367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial W (20 ) -422 <br /> CITY 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stan ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATU DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Consultant <br /> If APPLICANT is not the BILL/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: Soil Suitability Study/Nitrate Loading Study Review, Pp�YN"t—1 Ct <br /> COMMENTS: <br /> �'fJ/ulsrT+v^: �4 SAI1 <br /> 30p, t4v'l- <br /> T <br /> C%� �„r�r ( � ENTH DEPARTMEN <br /> APPROVED BY: t _ AL-1' EMPLOYEE#: DATE: <br /> ASSIGNED TO: <br /> EMPLOYEE#: s�� DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: S Z P E: .(- <br /> Fee Amount: S_ c]O Amount Paid B Payment Date Q 6 <br /> Payment Type Invoice# Check# 1 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />