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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> [5(Ztyb 4 (�c <br /> OWNER I OPERATOR ❑X <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 33510S Koster Rd. Lodi 95376 <br /> Street Numbar ection Street Name Zi 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 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (209)835-2792 255-160-02 -23 -24 PA 04-23 (MS) <br /> PHONE#2 EXT, <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK It BILLING ADDRESS <br /> Dave Welch <br /> BUSINESS NAME PHONE# EM' <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 /> 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 done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,,JSTATE and FEDERAL laws. '2 <br /> APPLICANT'S SIGNATURE: DATE: J -)d -a( <br /> PROPERTY/BUSINESS OWNER 13 ( OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT® <br /> 1fAPPL/c4NT is not the BrLLryG 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 environmentaUsite 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: Soil Suitability <br /> COMMENTS: 3/1 I Y (6 I E <br /> JAW MAR 10 2006 <br /> VZ8/0l� 1)Olyy� L SAN JOAQUIN COUNTY <br /> { <br /> ENVIRONMENTAI <br /> APPROVED BY: L t V E- 1 e EMPLOYEE#: ('J 3 L/ ATF: V 2L <br /> ASSIGNEDTO: `7—AK1O-P'DLLL-0S. EMPLOYEE#: r-F-6q DAI[: /oOkj <br /> �t4 Date Service Completed (If already completed): SERVICE CODE 5-2-Z PIE:-26'0/ <br /> Fee Amount: (�"(p . Amount Paid 1 e (� Payment Date I O UCJ <br /> Payment Type <br /> Invoice Check# S 33S F,eceived By: N (�- <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />