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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5c00 , 2 '--)9 <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> Michael & Li,-,a Douglas <br /> FACILITY NAME <br /> Wine CupM �tor oach Resort <br /> SITE ADDRESS 4620 E. Woodbridge Road Woodbridge 95258 <br /> Street Number ection Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 490 Moore Road <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Woodside CA 94062 <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> ( 650)529-9663 017-090-02 & -35 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION gODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Nancy Kramer <br /> BUSINESS NAME PHONE# EXT. <br /> Neil 0- Anderson and As,;ociatps, Inc- (209)367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209)369-4228 <br /> CITY STATE CA ZIP 95240 <br /> Lodo <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 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 /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ O .RATOR/ NAGER ❑ OTHER AUTHORIZED AGENT❑ Cu..s"1 _�— <br /> '-i c <br /> If APPLICANT is not the BILLING PARTY,proof c f 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 and Nitrate Loading Study Review RECEIVED <br /> COMMENTS: <br /> NOV 1 4 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: /v P i E: Z <br /> Fee Amount: p a° Amount Paid fk Lfgo Co Payment Date <br /> Payment Type L Invoice# Check# �(o Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />