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SAN JOAQUIN COUNTX ENVIRONMENTAL HEALTH DEPARTMENT <br /> k <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY.10# SERVICE REQUEST# <br /> OWNER/OPERATOR Mr. and Mrs. Ruiz CHECRIfBILLING ADDRESS <br /> ❑ <br /> FACILITY NAME <br /> SITE ADDRESS 31313 S Bird Road Tracy 95304 <br /> Street Number Direction <br /> tree Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> 1 <br /> PHONE#1 <br /> ExT. APN# LAND USE APPLICATION# i <br /> _ <br /> ( 209) 836-6400 1253-310-04 IA—eb GW9 <br /> PHONE#2 Exr. BOS DISTRICT LoCA'n �C�?DE <br /> I 1 ] YI �1f � <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Nancy R. Kramer CHECK If BILLING ADDRESS® <br /> PI <br /> BUSINESS NAME HONE# E)r. <br /> Neil O. 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 />°a 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,Standard STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATUR DATE: <br /> PROPERTY/BUSINESS OWNER PERATOR/A9A AGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANTis 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 /> 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 /> info Q _ <br /> provided to me or my representative. Ay .i s-� <br /> TYPE OF SERVICE REQUESTED: SOLI Suitability Study RECIEIVE.D <br /> o.f .Cn.J <br /> Comm� 'Y'a1 v� , ` o�� �?����� q Ilr�o(o -- a � AUG 2 9 ?oos <br /> ` 4 <br /> SAN,IOIlQU1h1 COUNTY <br /> ENVIRONMENTAL <br /> HFALTH DEPARTIVIEW <br /> APPROVED BY, EMPLOYEE#: q( <br /> DATE: C Z cj (lj <br /> v.. _ EMPLOYEE#:` DATE: �.rj <br /> ASSIGNED TO: , (��J <br /> Date Service Completed (if already comple d): SERVICE:CODE: S 71Z— P I E:�,2(P Q <br /> Fee Amount: Amount Paid: b t . . Payment Date g 'Z <br /> Payment Type Invoice# Check# Received By: {� <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />