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SAN JOAQUIN COUNTY ENIVIRONMENTAL HEALTH DEPARTMENT <br /> SkRVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S2�U S � ZC,%y <br /> Agriculture <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> DHV, LLC <br /> FACILITY NAME <br /> SITE ADDRESS 6686W Kile Road Lodi <br /> Street Number Dire tion <br /> Street eme ci Zio Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 7947 W. Kile Road <br /> Street Number Street Name <br /> CITY STATE CA ZIP 95242 <br /> Lodi <br /> PH0NE#1 Ea'' APN# PLANDAPPLICATION# <br /> (209 ) 327-1730 011-120-02 <br /> PHONE#P Ems• RICT LOCATION ODE <br /> ( ) QC <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> rM <br /> REQUESTOR CHECK If BILLING ADDRESS La <br /> Tamara Woods <br /> PHONE# E.T. <br /> BUSINESS NAME <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 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 /> COUNTY Ordinance Codes,Standards,STATE and <br /> dFFEDERAL <br /> ,laws. <br /> APPLICANT'S SIGNATURE: ��/7� G, �'�'r/ cG� I/�b V"AT <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Fnvironmental ConsLIita_nt <br /> IfAPPLICANT is not the BILLING 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: Surface Subsurface Contamination Report VIED <br /> COMMENTS: 7 MAY 12 2008 <br /> SAENOROUIN COUNTY <br /> / / HEALTH DEPARTMENT <br /> o M+a.n ¢i <br /> APPROVED BY: EMPLOYEE#: G,3 L DATE: s / O(Y+ <br /> f"Jlf�'Er12l+ <br /> ASSIGNED TO: EMPLOYEE#: 5'>(�,�, DATE: J// �Y 9' <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: I, PIE: -4.0� <br /> Fee Amount: - Amount Paid Cl Payment Date S (2 1 OF <br /> Payment Type ✓ Invoice# Check# a�� 5 /� Received By: U <br /> SERVICE REQUEST FORM <br /> EHD 48-01-025 <br /> REVISED 6-5-02 <br />