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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#� <br /> Vacant J )o �'�� <br /> OWNER/OPERATOR <br /> Mike Sandhu of Sandhu Brothers Farms CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME 23577 S. Mountain House Parkway <br /> SITE 3577 DDRESS S. Mountain House Parkway Tracy 95304 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) S. Chrisman Road <br /> 31995 Street Number <br /> Street Name <br /> crTM Tracy SATATE zIP <br /> C95304 <br /> PHONE#) EXT. APN# LAND USE APPLICATION# <br /> ( 209) 612-1127 209-080-26 PA-1900039 MS SR0080550 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Tony Mikacich CHECK if BILLING ADDRESS123 <br /> BUSINESS NAME PHON # EXT. <br /> Terracon Consultants Inc. 209) 367-3701 <br /> HOME or MAILING ADDRESS 902 Industrial Way FAX# <br /> (209) 333-8303 <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 /> 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 /> CoLNTI'Ordinance Codes,Standards,STATE and FZDERAL laws. <br /> APPLICANT'S SIGNATURE: � DATE: �/ �(G 2UI M/ <br /> PROPERTY/BUSINESS OWNER❑ "RATOR(A 1ANAGER ❑ OTIIER AUTHORIZED AGENT® (� (�: �:+T.�.✓� ✓ <br /> IfAil't/(-v is not the Birc.itic P IRTI,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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sa �1witlis <br /> provided to me or my representative. r �Ai71 <br /> TYPE OF SERVICE REQUESTED: Review of Amended Surface and Subsurface Contamination Report <br /> COMMENTS: f <br /> 0 <br /> JOA <br /> CNIjIN M/COU T y <br /> DEPgRNT <br /> SNF T <br /> ACCEPTED BY: S. Shih EMPLOYEE#: DATE: November 16, 2020 <br /> ASSIGNED TO: S. Shih EMPLOYEE#: DATE: November 16, 2020 <br /> Date Service Completed (if already completed): SERME CODE: 523 P 1 E: 2603 <br /> Fee Amount: $304 Amount Paid( -5614, 00 Payment Data <br /> Payment Type Invoice# Check# 0 Recelved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />