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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> Emily Katzakian (J & A Solari Inc.) <br /> FACILITY NAME Katzakian Residence <br /> E SITE ADDRESS 12133 Baker Road Stockton 95204 <br /> Street Number irection Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P.O. BOX 788 Street Number Street Name <br /> CIST�TE zIP 95236 <br /> Zinden a <br /> PHONE#I Err. APN# LAND USE APPLICATION# <br /> L ) 089-160-19 <br /> Exr. BOS;DlsTFZICT Locano COD1 <br /> PHONE#2 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR `/ <br /> ✓� CHECK if BILLING ADDRESS <br /> It <br /> BUSINESS NAME PHONE# E"T. <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS I FAX# <br /> 902 Industrial Way (209 )369-4228 <br /> CITY 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 /> or activity will be billed to roe 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,STAT nd FEDERA aws. <br /> APPLICANT'S SIGNATURE: DATE: 7 d5 <br /> PROPERTY 1 BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZER AGEN4# <br /> i' If APPLICANT is not the BILLING PAR proof.of authorization 10 sign is required itl e <br /> 1 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 environmentausite 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: �� G <br /> COMMENTS: RECEIVED <br /> JUL - 7 2009 <br /> SAN JOAQUIN COUNTY <br /> HEALTH!]PA <br /> ENVIRONMENTAL <br /> EIVT <br /> APPR E EMPLOYEE#:� DATE: d <br /> ASSIGNED TO: EMPLOYEE#: — DATE: <br /> )]ate Service Completed (if already co-"pieted)::. . SERVICE CODE: P 1 E' <br /> Fee Amount a/G. �� Amount Paid jd � Payment Date <br /> Payment Type invoice# Check# Received By <br /> {' EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED$-5-02 <br />