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r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> W70.,257 <br /> OPERATOR Cochran Properties 1 Paul Bowman CHECK if BILLING ADDRESS❑ <br /> I� <br /> FACILITY NAME <br /> SITE ADDRESS 33 , r_ '9.n Bird Ante. Tracy 95367 <br /> Street N mber irectiStreet Name Ci Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> $20 Eucalyptus <br /> Street Number treat Mame <br /> CITY Hillsborough STATE CA zip94010 <br /> PHONE#t ExT. APN# LAND USE APPLICATION# <br />} 17071765-6828 239-110-04 <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> Tina Cheney CHECK if BILLING ADDRESSID <br /> BUSINESS NAME PHONE# ExT. <br /> Neil O. Anderson &Associates Inc. 1209 367-3701 <br /> HOME Or MAILING ADDRESS FAX# <br /> 1 902 Industrial Way (209 )369-4228 <br /> CITY Lodi <br /> STATE (fQ__ ZIP Q.r]`�4�}_=�r—._�. ,r <br /> •. <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPART] [ <br /> or activity will be billed to me or my business as identified on this form. Q (t—,–" <br /> I also certify that I have prepared this application and that the work to be performed: <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. -���. � <br /> U <br /> APPLICANT'S SIGNATURE: <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORi <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,the o `� Q <br /> above site address, hereby authorize the release of any and all results, geotech: <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a <br /> provided to me or my representative. <br /> TYPE OF SERVICE-REQUESTED: <br /> COMMENTS: <br /> JUN 3 2006 <br /> (7 <br /> SAN JOAQUIN COLL'N <br /> ENVIRONME <br /> i APPROVED BY: EMPLOYEE#: D 2 r <br /> ASSIGNED TO: 16 ab a EMPLOYEE#: ! - DATE: <br /> ' Date Service Completed (if alreacom <br /> dy ]eted): SERVICE CODE: f P/E: I <br /> Fee Amount: Amount Paid Payment Date � `S 1 <br /> Payment Type Invoice# Check# Received By: <br /> i <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />