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SAN JOAQUIN-W—OUNTY ENVIRONMENTAL HEALTH 06ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> JIB C,i"' (0C qL <br /> OWNER/OPERATOR <br /> Bud and Donna Harris CHECK If BILLING ADDRESS® <br /> FACILITY NAME <br /> SITE ADDRESS12420E Tokay Colony Road Lodi95240 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 12747 Tokay Colony Road <br /> Street Number Street Name <br /> CITY Lodi, CA 95240 STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 931-5908 063-220-31 PA-04-267 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Abby Racco <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME Or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209 )369-4228 <br /> CITY Lodi STATE CA z'P 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 DEPARTMEN'r 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 be performed will be done in accordance with all SAN JOAQUIN <br /> \ COUNTY Ordinance Codes,Standards,S TE and FEDERAL I <br /> X APPLICANT'S SIGNATURE: DATE: Jo�j —/j —C� <br /> PROPERTY/BUSINESS OWNEn�ti. OPERATOR/MANA OTHER AUTHORIZED AGENT❑� PAYME ED <br /> /f APPLICA-N//jj''rs not the BILLING PARTY,proof of authorization to sign is required Ti Ne <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property loc t I� 4 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/sit 9c s�d+tt200 <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same timet NTY <br /> provided to me or my representative. SAN 3DA�NIME O AI- <br /> 4 1 <br /> � HEALTH U RTMENT <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Please review the attached Soil Suitability Stu , The report review fee of$186 will be paid <br /> by Mr and Mrs. Harris. If you have any questions, please do not hesitate to c Abby I <br /> APPROVED BY: EMPLOYEE#: DATE: Z <br /> ASSIGNED TO: 41i4�'4 <br /> EMPLOYEE#: DATE: C_ <br /> Date Service ompleted (if already completed): SERVICE CODE: C PIE: <br /> Fee Amount: Amount Paid 6 D Payment Date (O f (0 y <br /> Payment Type ✓:% Invoice# Check# 3G�5� Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />