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SAN JOAQUIN COUNTY ENVIRONMENTA!iHEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> R usser Property <br /> SITE ADDRESS 11964 E Liberty Road Galt 95632 <br /> Street Number 'o tree[ city Zio Cod. <br /> HOME or MAILING ADDRESS (If Different from Site Address) East Liberty <br /> 12000 Street Number <br /> Street Name <br /> CITY STATE ZIP <br /> Galt California 95632 <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> ( ) unassigned —p(j —!� <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# En' <br /> HOME Or MAILING ADDRESS FAX# <br /> 902 Industrial Way (2Q9)369-4228 <br /> CITY Lodi <br /> 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 /> 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,Standards,STAT nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: - ' DATE: <br /> ` PROPERTY/BUSINESS OWNER El OPsa ATOR7MANAGER 13 OTHER AUTHORIZED AGENTO <br /> 1fAPPLLCANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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. N� <br /> TYPE OF SERVICE REQUESTED: Soil Suitability Study <br /> COMMENTS: �—9 to <br /> �� T� <br /> APPROVED BY: EMPLOYEEM DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> 1 <br /> Fee Amount: UJ Amount Paid Z 14(o CFC) I <br /> Payment Date Qif0-7 <br /> Payment Type Invoice# Check# a-�� Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />