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A <br /> SAN 3OAQ6N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> James Thomno CHECK If BILLING ADDRESS El <br /> FACILITY NAME <br /> Thoming and Sons <br /> SITE ADDRESS --T 32350 State Route 33 Tracy q <br /> Street Number Direction Street Name cityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 33600 Koster Road <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> Tracy California 95376 <br /> PHONE#1 EXT. APN# FBOS <br /> ND USE APPLICATION# <br /> 209) 835-2792 255-150-08 PA-05-340 (MS) <br /> PHONE#2 EXT. DISTRICT �- LOCATION C DE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Nancy Rosulek CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Neil O. Anderson & Associates 209 367-3701 221 <br /> HOME Or MAILING ADDRESS FAX# <br /> (2 9)369-4228 <br /> CITY Lodi STATE CA ZIP 95240 <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> DATE: P�•'G, <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <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 JOAQUIN COUNTY ENVIRONMENTAL HEALTII 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 Study Review RECEIVE <br /> COMME#TS: <br /> vJ- f yg�°S ' DEC 1 5 2005 <br /> 5 SAN JOAQUIN COUNTY <br /> t O L v" ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: EMPLOYEE#: � ) DATE: /� S <br /> ASSIGNED TO: EMPLOYEE#: J b DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: SZL P I E. b/ <br /> Fee Amount: �� Amount Paid , IJu Payment Date Z \ S I O S <br /> Payment Type Invoice# Check# Z Received By: 11\� <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />