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SAN JOAQUIN-COUNTY ENVIRONMENTAL HEALTH MPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> v�200 `/ 7 v,3 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS X <br /> FACILITY NAME <br /> Ana a Pro ert <br /> SITE ADDRESS 16848 <br /> treeumber N Tully Road Lodi <br /> St NDirection Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 603South Central Avenue <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Lodi CA 95240 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) 053-030-10 PA-04-476 c <br /> PHONE#2 ExT. BOS DISTRICT ,\�,1, LOCATION COPE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Npil 0- Andemon and Assodates, Inc ( 209)367-3701 <br /> HOME Or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209)369-4228 <br /> CITY LodSTATE CA ZIP 4 <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 ness as identified on this form. <br /> y� I also certify that I have prepared th' pplication and that the work to be performed will be done in accordance with all SAN JoAQU►N <br /> L COUNTY Ordinance Codes,Standa s,S ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: / <br /> PROPERTY/BUSINESS OWNER❑ RATO /MANAGER ❑ OTHER AUTHORIZED AGENT 0 <br /> if APPLICANT is no i /LUNG ARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEA INFORMATION: When applicable, 1,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. " nzvaI <br /> TYPE OF SERVICE REQUESTED: Soil Suitability Stud <br /> COMMENTS: .y <br /> / Y/ p r <br /> [�ini.- ✓�� = td^i�[I T1pNQJtD1��TPti <br /> ?MEAT <br /> of <br /> Lz 1A <br /> / NAL <br /> APPROVED BY: - EMPLOYEE#: (^ DATE: / <br /> ASSIGNED TO: EMPLOYEE#: V/& DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: Z Z P 1 E: 2 <br /> Fee Amount: �C, Amount Paid (o Payment Date b <br /> Payment Type Invoice# Check# O y Received By: G <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />