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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID it ERVICE REQUEST# <br /> 5(L b 4 (0 <br /> OWNER I OPERATOR QX <br /> CHECK If BILLING ADDRESS <br /> Mr Jim Thommop <br /> FACILITY NAME <br /> 2 <br /> SITE ADDRESS 33510 S Koster Rd. Lodi 95376 <br /> Street Num bar I Diretion Street Name Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 33600 Oster Rd. <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Tracy CA 95376 <br /> PHONE#1 Ex. APN 1 LAND USE APPLICATION# <br /> (209)835-2792 255-160-02 -23 -24 PA 04-23 (MS) <br /> PHONE#2 Eu. <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Dave Welch <br /> BUSINESS NAME PHONE# Exr' <br /> Neil 0. Anderson and Associates. Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209)369-4228 <br /> CITY Lodi STATE CA ZIP <br /> 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 JOAQUYN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OwNERO /' OPERATOR/MANAGER O OTHER AUTBORIZED AGENT® <br /> I,fAPPLICANT 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 t0 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: Soh Suitability <br /> COMMENTS: 3�t I =--� 4 C $Y,('rC M FS l C9' I E <br /> l <br /> r46 -.. MAR 10 2006 <br /> 0,,,� SAN JOAQUIN COUNTY <br /> rci!!! ENVIRONMENTAI <br /> F�ry,•r/r_ <br /> APPROVLn 3'.: (�L l V .�-_I e EMPLO`r .'r: (0 3 LI AiF- .l t/1�' <br /> ASSIGNED TO: TAS 10-P-0 LLLOS EMPLOYLL(F: rL.G Lf DA , 0'& <br /> Date Service Completed (if already completed): SERVICE <br /> CODE: P!E: —�2 6,of <br /> Fee Amount: [kp .fZ Amount Paid Payment Date (� <br /> Payment Type - Invoice# Check A S 3 3 S Racewed By: <br /> EHD 48-01-025 SERVICE REQUEST FOR <br /> REVISED 6-5-02 <br />