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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OVVNER/OPERATOR Brad Klump CHECK If BILLING ADDRESS <br /> FACILITY NAME Klump Property <br /> SITE ADDRESS 17201 Seidner Road Esc Ion 95320 <br /> Street NumEer Direct' Street Nam 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 W. APN# LAND USE APPLICATION# <br /> (209)838-7049 1 229-160-15 Unassigned <br /> PHONE#2 Er. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Nancy Rosulek CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# Exr' <br /> Neil O. Anderson &Associates Inc. 1209 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 /> COUN'T'Y Ordinance Codes,Standards,S TE and FEDE aws. <br /> APPLICANT'S SIGNATURE: Neil 0.A e o 'etas,loo. DATE: +-, 1'97• Oto <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER O OTHER AUTHORIZED AGENT® Consultant <br /> 1fAPPLICANT is nal 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: .Soli .Suitability .Study <br /> COMMENTS: y 2D O5 , (6a,�et,� �>"yoiiir <br /> RF,NI <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNEDTO: EMPLOYEE#: 0 q DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 0/ <br /> Fee Amount: Amount Paid Payment Date //J/ <br /> Q <br /> Payment Type Invoice It Check# e Re eived By:" <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />