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SAN JOAQUI.' OIUNTY ENVIRCNN1Ei,TALHEALTF1 PI-M?ARTNIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ` $ERVIC ;REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Mr. and Mrs. Reece <br /> FACILITY NAME <br /> Reece Pro ert <br /> SITE ADDRESS 30850 S Highway 33 Tracy � 6— <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) P.O. Box 299 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Tracy <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# \ <br /> ( ) 255-320-01 & 255-320-02 —Uriz�ed <br /> PHONE#T EXT. BOS DISTRICT r LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �/ <br /> CHECK If BILLING ADDRESS X <br /> Dave Welch <br /> BUSINESS NAME PHONE# EXT. <br /> Ned 0- Anderson and Assoc*ates 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: 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 /> 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,stand% ds PATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE. y �_ DATE: 2 J <br /> PROPERTY/Bi.SINESSOWNER❑ OPERA,rOR/MANAGER ❑ OTHER AtTHORILEDAGENTO Consultant <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AI THORIZATION 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 elnironmental!site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN"r 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: ' <br /> Please review the following Soil Suitability Study. We hive attached the service reYiv `!� <br /> of$186. If you have any questions please call. <br /> Dave <br /> CIZa doad sArtJOAQUIN c:' <br /> l, <br /> Nt <br /> APPROVED BY: L/�J' �^) - EMPLOYEE#: 16 DATE: F D RT'C4 C111 <br /> = r <br /> ASSIGNED TO: 1 EMPLOYEE#: /�/L' DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 7 P 1 E: - 1 <br /> Fee Amount: Amount Paid D Payment Date 3 OS <br /> Payment Type ✓ Invoice# Check# 3-7 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />