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_ SAN JOAQU*-wCOUNTY ENVIRONMENI'ALHEALTH'/'PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERAtOR CHECK If BILLING ADDRESS <br /> Mr John Sandbop <br /> FACILITY NAME <br /> Time Oil Propert SITE ADDRESS 13475 N Jack Tone Road Lodi 1 Zip Code <br /> 95240 <br /> Street Numbx D'rection Stre tName <br /> HOME or MAILING ADDRESS (If Different from Site Address( <br /> Sheet Number treet a e <br /> CITY n STATE '^ ' ZIP <br /> PHONE#1 L ExT. APN# LAND USE VAPPLICATION# <br /> I I 1 063-260-04 Unassigned �,•�Y�" <br /> PHONE#2 EJ . SOS DISTRICT LOCATION C DE <br /> 1 1 <br /> CONTRACTOR / SERVICE REQUESTOR �A <br /> REOUESTOR CHECK If BILLING ADDRESS© i <br /> nave WeIcb <br /> BUSINESS NAME PHONE# Exr' <br /> 6Q A�nn <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (2 1 <br /> CITY Lodi <br /> STATE CA ZIP <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,Standar TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE S. I \ DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTNERAUTHORaED AGENT® Consultant <br /> /fAPPUCANT is not the BILLING PAR TY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property locat"tWI ENT <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site a psltr�E.NIEQ <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL,HEALTH DEPARTMENT as Soon as it Is available and at the same frme it is <br /> provided to me or my representative. f" - ' zoos <br /> TYPE OF SERVICE REQUESTED: SOLI Suitability Study ReVIE!W 1\lrf'a4-2 11 CO <br /> COMMENTS: EN "S <br /> Please review the following Soil Suitability Study. Mr. Sandhop from Time Oil Compan NVIWARON QE IENIT dT <br /> will attach the service review fee of$186. If you hpve any questions plea 7e Fal <br /> 3 <br /> APPROVED BY: E YE <br /> ASSIGNED TO: EMPLOYEE#: /,-, DATE: <br /> Date Service Completed (if already completed : _ (r�UO SERVICE CODE: 5`Z PIE: Z ; I �O 2 <br /> Fee Amount: f mount Paid J$ Payment Date 3 Zy 05 <br /> Payment Type Invoice# Check# I Received By: <br /> ?ae <br /> ( a a � <br /> EHD 48-01-025 I `(SERVICE REQViU�ESS1� <br /> �RM <br /> RVISED6-5-02 / '[&( <br /> 140 , C <br /> L) . <br /> Et ,1 <br /> -y' HFp'� <br />