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SAN JOAQUIN,COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Mr. Nick Sikeotis CHECK If BILLING ADDRESS <br /> FACILITY NAME Jessie's Grove Winery <br /> SITE ADDRESS 1973W. Lodi Turner Road 95242 <br /> Street Number Direction Street Name Citv 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 /> ( ► <br /> 1013-050-17 UP-98-3 <br /> PHONE#2 EXT. BOS DISTRICTLO1[ CATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> David Welch 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: 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 that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand ,S ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATUR DATE: dD 0. C <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/NIANAGER ❑ OTHER AUTHORIZED AGENT® COn ultant <br /> If APPLICANT 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: ;' ! rF i ( _�,4 <br /> COMMENTS: Per the request of the client, we have submitted the SSS/NLS along with the expedite w N-T <br /> II JJ <br /> feeof$930 ($465*2). If you have any questions, please do not hesitate to call. , , - ECEI ED <br /> Nov 2 <br /> � Li> , � qN J COUNTY <br /> APPROVEDBY: EW <br /> ASSIGNED TO: S �A EMPLOYEE#: ZL;:,— J <br /> DATE: I( 2 l `t <br /> Date Service Completed (if already completed): SERVICE CODE: �Z S !"Z S E: <br /> Fee Amount: L� Amount Paid Payment Dat <br /> D a <br /> Payment Type Invoice# Check# (o�tf Received By: L <br /> EHD 025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 �DD0rL( CnS � 8 � <br />