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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# gRVICR 4llEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Mrs Kathy Reinstein <br /> FACILITY NAME <br /> Thomsen Farms Inc <br /> SITE ADDRESS 99 E Blewett Road Tracv 95304 <br /> Street Number I Directlon a City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 3CC West Durham Ferry <br /> 2 SV a Number Street Nama <br /> Clry STATE ZIP <br /> Tracy CA 95304 <br /> PHONE#1 Ems. APN# LAND USE APPLICATION fic5 - pad73 <br /> (209)835-5442 255-180-01 & 13 Unassigried <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (209)914-2580 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Nancy Rosulek <br /> BUSINESS NAME PHONE# En. <br /> Nizol C) Anderson cand Associates Inr 19091367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209)369-4228 <br /> CITY I ode <br /> 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---1 ct <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 SAr IN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: t ,� . DATE: 11— 05 <br /> PROPERTY/BUSINESS OWNER❑ OERATOR/MANAER ❑ OTHER AUTHORIZED AGENT® 4::� <br /> If APPLICANT is not the BILLING PARTY proof ofauthorizadon 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 /> TIDE OF SERVICE REQUESTED: Soil Suitability <br /> Zbility Study Review /^ AYMENT <br /> COMMENTS: /L !�f �P /�.r y- 4101-111 <br /> NOV 15 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> APPROVED BY: ('J[�(V>E, EMPLOYEE#:©!�Z-4 DATE: I( <br /> ASSIGNED TO: VA-N NC-- EMPLOYEE#: Z(06CD DATE• It <br /> Date Service Completed (if already completed): SERVICE CODE: s2.2 P/E: z( I <br /> Fee Amount: ( ,ITS Amount Paid '(e(o .W Payment Date 1( (S Of <br /> Payment Type �(er(C, Invoice# Check# g rp g Received By: C� <br /> EHD 48-01-025 - - SERVICE REQUEST FORM <br /> REVISED 6-5-02 `� <br />