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SAN JOAQUIN COUNTY ENVIRaNMENTALHEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK IT BILLING ADDRESS <br /> Mrs, K;;tby-Re'nqtp*n <br /> FACILITY NAME <br /> Thomsen Fa s Inc <br /> $READDRESS 99E Blewett Road Tracy 95304 <br /> Street Number DirectionI Nam, cityCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3G'pp West Durham Ferry <br /> 25tr a Number Street Name <br /> CITY STATE ZIP <br /> Tracv CA 95304 <br /> PHONE#1 Exr. APN# LAND USE APPLICATION Is <br /> (209)835-5442 255-180-01 & 13 Unassigned — <br /> PHONIER BOS DISTRICT LOCATION CODE <br /> ( 209)914-2580 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Nancy Rn,;tjlpk <br /> BUSINESS NAME PHONE# <br /> Nail 0 Anderson and Aq,;nr*atpq Inc I <br /> )367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial W (209)369-4228 <br /> CITY Lodi <br /> STATE CA ZIP <br /> 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 forth. <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, TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: IZ • '�,�1'��— <br /> PROPERTY/BUSINESS OWNER OERATOR/MANAER ❑ OTHER AUTHORIZED AGENT© C:-, C . T' <br /> {fAPPLICANT is not the BILLING PARTY proof of aalhorizadon 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 envirotunental/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 SERVICEREOUESTED: Surface Subsurface Contamination Report Review RECRvy=IVILNTP <br /> COMMENTS: <br /> LlE(, 7 2005 <br /> SANJOAQUIN NOTUTY <br /> ENVIRONM,, �I LeIdel HEALTH DEPARTMENT <br /> APPROVEDBY: O�-CVEfTo EMPLOYEE#: 03z-/ DATE: 12-( /6S <br /> ASSIGNED TO: v OkAJ AJ&— EMPLOYEE#: 4to o DATE: / 2-/7OS' <br /> Date Service Completed (If already completed): SERVICE CODE: S�s PIE: <br /> Fee Amount: 00 1 Amount Paid 1 Payment Date I �5 <br /> Payment Type Invoice# Check# 0A Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />