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l <br /> SAN JOAQUIN COUNTY ENVIRONMENTALHEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5(zoo y f <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Dutra Property <br /> SITE ADDRESS 16113 S Victory Road Oakdale <br /> Street Number 'r caon lamo C'III, Mp Code <br /> HOMEOr MAILING ADDRESS (if Different from Site Address) 1500 Standiford Avenue <br /> Sheet Number Street Nam <br /> CITY STATE ZIP <br /> Modesto <br /> PHONE#1 EXT' APN 0 LAND USE APPLICATION# <br /> 1 559 269 2419 229.220 2-y OH -73119 <br /> PHONE#2 Exr' BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR v <br /> CHECK if BILLING ADDRESS ^ <br /> Nancy Rosulek <br /> BUSINESS NAME PHONE# Ex . <br /> 0. <br /> )367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209)369-4228 <br /> CITY Lodi <br /> STATE CA 2:IP 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 /> COUNTY Ordinance Codes,Standards,STATE and FEDE L laws. <br /> I p <br /> APPLICANT'S SIGNATURE: o �.e- DATE: to 1 o b <br /> PROPERTY/BUSINESS OWNER 13 O ERATOR/MAN GER OTHER AUTHORIZED AGENT 13 <br /> If APPLICANT is not the BILLING PARTY proof of aathdrizaddn 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. PAYMEM <br /> TYPE OF SERVICE REQUESTED: .Soil .Suitability .Study Review <br /> COMMENTS: , h�__,� � �� JUN 0 5 2006 <br /> �`t'r°f SAN JOAQUIN <br /> ENVIRONMENTAL <br /> TM <br /> ��� •'u a HEALTH DEPARTMENT <br /> APPROVED BY: <br /> EMPLOYEE /_ DAT SA <br /> ASSIGNED TO: �— � �d � � �J EMPLOYEE Yom`/ DAT (/ <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date 6 s-7c (e <br /> Payment Type Invoice# Check# '�11 pD Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />