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S•aN,1(�A UI"',COUNTY ENVIRONMENTAL HEALTH DFPARTMEN-r <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Agriculture QQ jC�C��j <br /> OWNER/OPERATOR -- <br /> Joe Ratto CHECK if BILLING ADDRESS <br /> FACILITY NAME Ratto, Sarale & Del Carlo Property <br /> SITE ADDRESS 11981 S Roberts Road Stockton <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 2762 North Tracy Blvd <br /> Street Number Street Name <br /> CITY Tract STATE CA ZIP 95376 <br /> PHONE#1 EaT. APN# LAND USE APPLICATION# <br /> ( ) 191 -150-03 PA-08-027 MS <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Nancy Kramer 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 /> CITYLodi STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 dune in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE:DATE: `p/?j/O <br /> PROPERTY/BUSINESS OWNER 4EPLATOR/ ANAGER ❑ OTHFR AUTHORIZED.AGENT❑ __��,,�t•�• 1 <br /> /f APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> A±JTHORIZATION 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 JOAQUTN CotJNTY 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 IVED <br /> COMKIENTS: <br /> JUN 3 MB <br /> SAN JOAOUIN COUNTY <br /> HFA H DEPARrTM-IN <br /> APPROVED BY: EMPLOYEE At: 2 013 DATE: <br /> ASSIGNED TO: EMPLOYEE#: (�-< DATE: <br /> Date Service Complete (if already completed): SERVICE CODE: sw P 1 E: <br /> Fee Amount: Or- Amount Paid l 8FDPayment Date b <br /> Paymen°TypeInvoice# Check# a g( Received By: <br /> EHD 48-01-025 ay(�� V" ' SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />