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7 c <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS X <br /> FACILITY NAME <br /> SITE ADDRESS 14645 E Tokay Colony Road Lodi 95240 <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209)931-9333 065-270-02 00 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ► <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Daniel Kramer <br /> BUSINESS NAME PHONE# EXT. <br /> Neil 0. Anderson and Associates, Inc. ( 209)367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 2 Industrial W (209)369-4228 <br /> CITY 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,Standards ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: pit. ldddfi� DATE: 10-3-02 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT O <br /> If APPLICANTis 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 tIf same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED:Soil Suitability Study WA�T/E(Z <br /> COMMENTS: l� �( I /Z n �5 Ole 1 <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: // DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 2 L P/E: <br /> Fee Amount: Amount Paid Z�-,ID Payment Date C� 3 <br /> V <br /> Payment Type Invoice# Check# q 3q 3 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />