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t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICEREQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 R-oo S Z <br /> OWNER/OPERATOR <br /> John Kooyman C/o Shoup Land Surveying Y CHECK if BILLING ADDRESS <br /> FACILITY NAI1fE Kooyman Property <br /> SITE ADDRESS 5525 <br /> W Turner Road <br /> Name Lodi 95242 <br /> Street Number Direction tree <br /> HOME or MAILING ADDRESS (If Different from Site Address) C' i Code <br /> (,'TTY Street Number Street Name <br /> $TATE ZIP . <br /> FPHONE#2 <br /> �T. APN# <br /> 333-1$72 (Shoup) LAND USE APPLICATION# <br /> 011-160-20 s� <br /> EXT. <br /> 368-2814 (John Kooyman} Bos DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REctuesroR <br /> Daniel Kramer CHECK If BILLING ADDRESS❑ <br /> r BUSINESS NAME PHONE# Err. <br /> p Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> f 902 Industrial Wa (2091369-4228 <br /> l CITY <br /> 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 /> f 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 JOA UrN <br /> COUNTY Ordinance Codes,Standards, T an DERAL laws. Q <br /> i ' <br /> APPLICANT'S SIGNATURE: <br /> ATE: <br /> y OPERTV t BUSINESS OWNER 13 _ O ERATOR/MANA R ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not t ILtl1yGP4xTY 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 i <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: Soil Suitability Study <br /> COMMENTS: /�� <br /> RECEIV <br /> 1 r <br /> DEC 18 2007 <br /> SAN J0A0uIN COUNTY <br /> ENVIRONMENTAL„ <br /> HEALTH DEPARTMEfy'I' <br /> APPROVED BY: EMPLOYEE#: <br /> DATE: <br /> ASSIGNED TO: 4-2 1Z <br /> EMPLOYEE#: <br /> DATE: i <br /> Date Service Completed (if already Completed]: SERVICE CODE: �Z j� <br /> PIE- <br /> Fee Amount: L b d' Amount Paid <br /> rr Payment Date <br /> Payment Type Invoice# Check# <br /> 1 3f..-7 �� Re slued y: <br /> EHD 48-01-025 <br /> REVISED 6-5-02 SERVICE REQUEST FORM <br />