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> ' SAN JOAQS10iCOUNTY ENVCtOi4 SNTALHEALTFMIIEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S VICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK It BILLING ADDRESS <br /> FACILITY NAME <br /> Bo etti Brothers <br /> SITE ADDRESS 35088S Welty Road Tracy <br /> Street Number Direction Street Nam CIN MY <br /> HOME or MAILING ADDRESS (If Different from Site Address) p0 Box 273 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr' APN it LAND USE APPLICATION# <br /> 209) 526-1515 255-260-16 PA-03-498 (MS) J <br /> PHONE#Y Exr. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Nancy Rosulek CHECK N BILLING ADDRESS <br /> BUSINESS NAME - PHONE# Ex. <br /> Neil O. Anderson & Associates 209 ) 367-3701 221 <br /> HOME or MAILING ADDRESS FAx# <br /> (209)369-4228 <br /> CITY LodSTATE CA ZIP 95240 - <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator—or ri C <br /> same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly ffarge sso th t S project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 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,STATE and FEDERAL laws. <br /> 1C J APPLICANT'S SIGNATURE: y� (��JJ � DATE: C(y <br /> —/2 —(sS <br /> PROPERTY/BUST\ESS OWNER❑ OPERATOR/`S1.aNAGER ❑ OTHER AUTHORIZED AGENT© <br /> /JAPPUCANT is not the BILLING PARTr.proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE 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. <br /> TYPE OF SERVICE REQUESTED: Soil .Suitability Study RECEIVED <br /> Sj7e �iSSE� J !l �u� SEP 19 2005 <br /> R° 'MIA,(A, Q ZI, 'L� �j�p SAN JOAOUW COUNTY <br /> r1 ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: G t L, ` I V''k EMPLOYEE M Ci 3'j,( DATE: Y !4(/6i <br /> ASSIGNED TO: (,iA" 1.3 ti: t EMPLOYEE#: (.F �, DATE: ct (CrCC S <br /> Date Service Completed (if already completed): SERVICE CODE: .S"L L PIE: <br /> Fee Amount: (� L,J Amount Paid 0 0 Payment Date OS <br /> Payment Type Invoice# Check# 13 -6 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 / <br />