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i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property JFACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR W T Hull & Co. - Terry Hull <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESs1018 & 1020 S. Carroll Ave Stockton 95215 <br /> Street Number Direction Street N citv zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 200 West Harding Way <br /> Street Number sweet Name <br /> CITY Stockton STATE CA ZIP 95204 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 644-6401 1159-083-10 <br /> PHONk#2 / EXT --^c nlc_TRICT _ LOCATION CODE' <br /> CONTRACTOR/ SERVIC' <br /> REQUESTOR Tina Cheney, t1� . <br /> BUSINESS NAME rj {r <br /> Neil O. Anderson & Associates Inc.: OO <br /> HOME or MAILING ADDRESS .�� 070,00(x3 Cts) <br /> 902 Industrial Wayt � cd0 • �� <br /> CITY Lodi ; p- <br /> s <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property of ime, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEAL Jject <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 b ac &+A-tc - -+ lam- + - �C-v3'0 QUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER <br /> Lf APPLlc-INT is not the BiLLiNG PARTY,proof of aathorizadon to sign is required Title <br /> AUTHORIZATION TO RELEASE INt;ORMATION: When applicable,1,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. Pq <br /> TYPE OF SERVICE REQUESTED: Surface & Subsurface Contamination Report ECEIVED <br /> COMMENTS: DEC O 5 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT' <br /> APPROVED 9Y. EMPLOYEE#:: DATE: <br /> ASSIGNED TO. EMPLOYEE#: DATE: Z Q <br /> Date Service Completed (If already completed): SERVICE Cooe: 3`S P 11E: <br /> .'2-603 <br /> Fee Amount: C. Amount Paid ' D V6 Payment Date Z` .S6-76 <br /> Payment Type. L,--1 Invoice# Check# 3 Received By: , <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />