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' SAN JoAQ04 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />' SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Agricultural/Resiential Sko o `I `] O "} <br /> OWNER I OPERATOR <br />" Ryan Vorhees CHECK tfMILLING ADDRESS <br /> FACILRY NME <br /> Thornton Project <br /> SITEAoomssThorton <br /> d West Walnut Grove Rd <br /> Street Number Di treat Name M Vp Code <br /> HomE or MAILING AmEss (If Different from Sing Address] 28082 <br /> Nichols Road <br /> bar stmat N m <br /> CITY Galt STATE CA zip 95632 <br /> PHONE#1 Exr• APN9001-140-74, 001-140-75, LAND USEAPPucATION$ <br /> 367-1706 001-140-67, 001-140-68, <br /> (209 1 1001-140-71, 001-140-72 <br /> PHONE#2 fir• BOS DISTRICT ,j LOCATION nOE <br /> - - - - -- CONTRACTOR l SERVICE REQUESTOR' - <br /> REQUESTOR ,ramie Drane CHECK if BILLING ADDRESS <br /> BUSINmNAMfe Chicago Title Company FBy 6# � <br /> 853-7653 <br /> HOME or MAIuNG ADDRESS FAX# <br /> 3075 Prospect Park Drive, Suite 130 ( 9161 638-1854 <br /> CITY Rancho Cordova <br /> � STATE CA 25p 95670 <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 /> i or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this i�lion and that the work to be performed will he done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar r4TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ SRP <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 /> i above site address, hereby authorize the release of any and all results, geotechnical data and/or envimnmental/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. 14 <br /> TYPE DF SERVICE/REQUESTED:/ "�"4 Nir� <br /> C01rr1 NTS ��!i 510 4 a=77. r41C_SS� --� tr G rzz �L! 7 lc Ca . �r <br /> !! tZo ,a,•t <br /> -�4-- acG�sS r'Vr...r5� ��Gr/uys'L.c'-`�e��•'�e�f v cry-.. �.`,�J �100�r�N <br /> Tti q�PAR-tM�t� <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> E ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Comp (if already completed): SERYE CODE: P t E: Zd <br /> Fee Amount: Amount Paid i o Payment Date 1p I E S (� <br /> Payment Type Elnoice# Check# S Received By: <br /> !'Z(Z3(/.. GE�f 11r su� �rs— �,e�a ►�rL,t—S =3-S <br /> EHD 48-02-025 C1 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <,—a, <br /> "'D C:e a V( <br /> ca <br /> h <br />