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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 00 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESSED <br /> Mr. David Payne <br /> FACILITY NAME <br /> D.L. Payne Inc. <br /> SITE ADDRESS <br /> Street Number Direction Street Na Cit Zi 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) 367-4858 051-180-18 %x0500323 <br /> PHONE#2 ExT. BOS DISTRICT ( LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Nancy Rosulek <br /> BUSINESS NAME PHONE# EXT. <br /> NP*I 0- Andemon and Assocoates, Inc, ( 209)367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209)369-4228 <br /> CITY LodSTATE 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 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 a plication and t a rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ATE and FEDE L laws. <br /> x APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER$ OPERATOR/MANAG' OTHER AUTHORIZED AGENT M Vy.e-J eE,e <br /> If ADPL/CANT 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 & Nitrate Loading Study �J f- <br /> COMMENTS: / y�� 1�ECEIVCD <br /> JAN 1 1 Z006 <br /> D 1�.�—\ SAENVVIAQUIN IRONM <br /> ENVIRONMENTAL <br /> APPROVED BY: EMPLOYEE#: <br /> ASSIGNED TO: EMPLOYEE#: DATE: // <br /> Date Service Completed (if already completed): SERVICE CODE: -y� P i E:;Z/, <br /> Fee Amount: ¢ Amount Paid �j `t (oS,6-t)I Payment Date ( t t O (o <br /> Payment Type Invoice# Check# 1 � Received By: <br /> iD 48-01-025 SERVICE REQUEST FORM <br /> VISED 6-5-02 <br />