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! t <br /> t <br /> SAN JOAQUIN COUNTY ENVIRONNVIENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br />! OWNER/OPERATOR <br /> AA Solari Inc CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> J&A Solari Property <br /> SITE ADDRESS <br /> ?-12133 E Baker Road Stockton <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS-(If Different from Site Address) PO BOX 788 <br /> Street Number Street Name <br /> j CITY STATE Zip E Stockton CA 95236 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) 089-160-19 �� - .e3 eins <br /> PHONE 92 ExT• <br /> BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Tamara Woods CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Neil 0. Anderson &Associates, Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS 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 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 FE ERAL laws, i <br /> s _ <br /> '/"APPLICANT'S SIGNATURE: --� DATE: 42-1,/'D <br /> PROPERTY/BUSINESS OWNER OPERATO I mV A R ❑ OTHER AUTHORIZED AGENT nt <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title j <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. <br /> TYPE OF SERMCE REQUESTED.' Surface Subsurface Contamination Report RECEIVED <br /> COMMENTS: FEB 2 6 2009 <br /> PGL 71 /G�cJG] d ww <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M \ DATE: <br /> 7 <br /> ASSIGNED TO: EMPLOYEE M S DATE: i <br /> I <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:Z o ' <br /> Fee Amount: 0 Amount Paid ` O Payment DatVD , Ie 2-1 Ve b <br /> Payment Type Invoice# Check# e 2 E t Re eived by: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />