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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ko 4 -7 I a S <br /> OWNER/OPERATOR <br /> Tom Hoffman CHECKNBILLING ADDRESSID <br /> FACILITY NAME BI <br /> SITE ADDRESS 1 E. Woodbridge Ro Acampo 95220 <br /> S NumberstName city Zip C.de <br /> HOME or MAILING ADDRESS S <br /> Street Number Sbeet Name <br /> CITY STATE ZIP <br /> PHONE#t En. APN# LAND <br /> USE APPLICATION# <br /> (209)369-8578 017-230-01 PA-06-33 (SA) <br /> PHONE#2 Ezi. BO$DISTRICT LOCATION CODE <br /> I I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex'' <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 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 /> 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,STATE Spa F BE L- WS. <br /> APPLICANT'S SIGNATURE: <br /> DATE: 2A Ci, <br /> PROPERTY/BUSINESS OWNER L7 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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: Review SDII Suitability/Nitrate Loading Study ) <br /> COMMENTS: " , <br /> 6/" 3/06 '`' t�ttt4s <br /> JUN 21 2006 <br /> . � Lid �+ r� C�•I_ SAN JOApUIN� COUNTY <br /> ENVIRONMENTAL' <br /> DEPARTAAPKM <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: Fad <br /> Fee Amount: S Amount Paid �.._S Q(, Payment Date <br /> Payment Type li- Invoice# Check# l i, i , Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />