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R SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �[ 5YQ-O-D q fis-g 9 o <br /> OWNER I OPERATOR <br /> Mr. Sam Freitas CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 2430S Drais Avenue Stockton 96215 <br /> Street Number Direction Street Name city I ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2420 E. Eight Mile Road <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95210 <br /> PHONE#1 ExT API# LAND USE APPLICATION# <br /> } <br /> (209)470-6933 183-230-13 Unassigned <br /> PHONE#2 EIIt. BOS DISTRICT LOCATION CODE <br /> M ( ) <br /> I CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Tina Cheney CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# En. <br /> Nell 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 /> N 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,STA E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is 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 /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: RECEIVED <br /> FEB 2 2 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> APPROVED BY: EMPLOYEE M ATE: <br /> u vii a 3 -f Z 3 f <br /> ASSIGNED TO: ��SC.C�—I�� EMPLOYEE#: L( DATE: & <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount:' j t (,• D� Amount Paid L Payment Date 2 2'Z 0 b <br /> Payment Type �� Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />