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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT • <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S 2 <br /> 0o +5 9 1 1 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Ralph Renna <br /> FACILITY NAME <br /> Delta Land LLC <br /> SITE ADDRESS 651W Sarqent Road Lodi 95242 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name � <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 368-7412 029-020-57 PA 05-580 (MS) <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Nancy Rosulek <br /> BUSINESS NAME PHONE# EXT. <br /> Npml 0- Anderson and Associates, Inc- ( 209)367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209)369-4228 <br /> CITY Lodi <br /> STATE CA ZIP 4 <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,STATE and FED RA ws. <br /> APPLICANT'S SIGNATURE: Z1_ DATE: Z/Z3 /c, <br /> G <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 0 <br /> If APPLICANT 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 JOAQUrN 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: 5 C7( L Su-t 7--,4 Q t i-,i Ty T--c-tJ 6�ECEIV ED <br /> COMMENTS: ^ VFB 2 �oo� <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: C L t t EMPLOYEE#: Q Z( DATE: 3 O <br /> ASSIGNED TO: ll {l, AJ EMPLOYEE#: 5`3( DATE: z 2-3 l U& <br /> Date Service Completed (if already completed): SERVICE CODE: Z P/E: ZG <br /> Fee Amount: ,p D Amount Paid /n , (D 0 Payment Date --) a-3(D 6 <br /> -ie ✓ Invoice# Check# Received By: <br /> 25 SERVICE REQUEST FORM <br /> 5-02 <br />