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SAN JOAQUIN COUNTY ENVIRONMEN'T'AL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ji�vo S � s o <br /> OWNER/OPERATOR San Joaquin Valley Land Co. CHECK if BILLING ADDRESSD <br /> FACILITY NAME New Moose Lodge <br /> SITE ADDRESS 3824 E. Woodbridge Rd. Acampo 95220 <br /> Street Number Direction Street Name ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 18141 Foreman Ct. <br /> C/o Frlls Constructors. Inc. Street Number Street Name <br /> CITY Linden STA LA <br /> ZIP 95236 <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> (209 ) 334-4297 Friis Constructors 013-220-52 PA-07-180 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco 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 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. J <br /> APPLICANT'S SIGNATURE: —�� �; Q, ��t f0(,DATE: <br /> PROPERTY/BUSINESS OWNER OPERATO /MANAGER OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BALLING 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 of Soil Suitability/Nitrate Loading Study RE EN7 <br /> COMME TS: 6 r� NO V <br /> Y 2007 <br /> Mia ' J SAN <br /> RONIN COUNTY <br /> MENTAL <br /> HEALTH DEPARTMENT <br /> APPROV Y: (--t L"�I �� EMPLOYEE#: C 5 DATE: a '.("1(27 <br /> ASSIGNED TO: J EMPLOYEE#: J` ] DATE: /i �, ((� � <br /> M n ! <br /> Date Service Completed (if already completed): SERVICE CODE: S L P/E: <br /> Fee Amount: (���0 Amount Paid c�C!� , Payment Date `l C 7 <br /> Payment Type C K Invoice# Check# 2-6s"17 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />