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SAN JOAQUt!w-i OUNTY ENVIRGNMENTAL HEALTH-V..rARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# E VIC�PEQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> Mr. and Mrs- Rpprp <br /> FACILITY NAME <br /> Reece Pro ert <br /> SITE ADDRESS 30850 S 45a:7-6— <br /> Street 33 Trac45a:7-6— <br /> Street Number Direction Street Name Citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P.O. Box 299 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Trggy CA 95378 <br /> \ <br /> PHONE#1 EXT. APN At LAND USE APPLICATION# <br /> ( ) 255-320-01 & 255-320-02 --Unasg4gned r <br /> PHONE#2 EXT. FtOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS X <br /> Dave Welch <br /> BUSINESS NAME PHONE# EXT. <br /> Neil 0- Andemon and Associates, Inc. ( 209)367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way ( 209)369-4228 <br /> CITY Loda <br /> 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,StanXdS ATEand FEDERAL laws.APPLICANT'S SIGNATUREDATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Consultant <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 Review <br /> COMMENTS: Please review the following Soil Suitability Study. We have attached the service reg( ,� /ED <br /> of $186. If you have any questions please call. <br /> Dave MAR 2 9 Z1105 <br /> SAN JOAQUINECOO TM <br /> M <br /> APPROVED BY: EMPLOYEE#: C DATE: -3 D TINIENT <br /> ASSIGNED TO: / r EMPLOYEE#: QI DATE: <br /> r <br /> Date Service Completed (if already completed). SERVICE CODE: `77 P I E: <br /> Fee Amount: 06 Amount Paid '0 Payment Date 3 (-S <br /> Payment Type ✓ Invoice# Check# Received By: Z� <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />