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SAN J0AQUII4'1 {- UNTY E5IVIRONMENTALHEALTH 1)%-WARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> 279 Ea t H m sI RoadProperty <br /> SITE ADDRESS 279 E Homestead Road Tracy 95304 <br /> Zip Cede <br /> Sheet Number a <br /> HOME or MAILING ADDRESS (If Different from Site Address) 26662 San Jose Road <br /> Street Number hee[N e <br /> CITY STATE ZIP <br /> Tragy QA— 95304 <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> I 1 239-160-16 15 2 &3 PA-04-468 <br /> PHONE#2 E> . BOS DISTRICT LOCATION CODE <br /> I 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTDR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EM' <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way2090369-4228 <br /> 1 <br /> CITY Lodi <br /> STATE CA ZIP <br /> 95940 <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 /> 1 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,Stan rds, TATE and FEDERAL laws. <br /> APPLICANT'S SIGNAT DATE: <br /> ER <br /> PROPERTY/BUSINESS OWNOPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Consultant <br /> If APPLICANT is not the BILLING PARTY,proof Of authorization t0 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. PP.Y IV1 E IST <br /> TYPE OF SERVICE REQUESTED: dz� it LL.. s2 n� <br /> COMMENTS: Please review the following Soil Suitability Stu . We have attached thEUVIRCENOAV fee <br /> of$186. If you have any questions please call. SAN IOAouw COUNTY 3 <br /> -/ Cy/ A p/ .5 ENVIRONMENTAL <br /> Dye. 0�/ / �.Y O/+t d/n'lG�p<? �� W/G/,��2•fp�qy.7 HEALTH DEPARTMENT <br /> EAPPROVEDOEMPLOYEE#: ATE �EMPLOYEE#: ATE: <br /> AsSIGN <br /> OV7 <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount ( Amount Paid Payment Date a D� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />