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S � <br /> ,• r SAN JOAQUIN COUNTY ENVIRON`1VIEN'fXLHEALTff DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE.REQUEST# <br /> 1620 0 � <br /> OWNER I OPERATOR Pete Vander Meulen CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Vander Meulen Property { <br /> SITE ADDRESS 132 sca on b0lota Road & Linden 95320 <br /> I� Street Number ai—tim 125883 Edwar a City 7iI2 Cade <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 13282 Escalon t3ellota Road <br /> Street Number Street Name <br /> CITY STATE CA ZIP 95320 <br /> Linden <br /> PHONE#t EXT' APN# LAND USE APPLICATION# l <br /> (209 ) 838-3731 207-200-09 ,b7` CID <br /> PHONE#2 ExT. BIDS DISTRICT- LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTO <br /> REQUESTOR Tamara Woods CHECK If BILLING ADDRESS <br /> BLISINESs NAME PHONE# ExT' <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way t209 )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 /> I 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 JOAQUrN <br /> COUNTY Ordinance Codes,Standards, E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE:/ 7/.;-> U 7 <br /> PROPERTY/BUSINESS OWNER_ _ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICRNT is not the BILLING,PAR 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 /> TYPEOFSERVICE REQUESTED: Surface Subsurface pontamination Report Review RECEIVED <br /> COMMENTS-11-(-".a101- <br /> JUL 3 1 Z007 <br /> / rI t SAN JOAQUIN COUNTY <br /> 0 ENVIRONMENTAL <br /> l` HEALTH DEPARTMENT <br /> APPROVED BY: Lt V E[ t� � EMPLOYEE#J`: ;,C)3f, DATE: +� <br /> ASSIGNED TO: ~r .PD L. -i-OS EMPLOYEE#: C)q_51 DATE: 3 f i7�-7 , <br /> Date Service Completed (if already completed): SERVICE CaDls:.,3 P 1 ��/ <br /> Fee Amount: Amount Paid Payment Date -113 6-1 I. <br /> �/pp- r: <br /> Payment Type. Invoice# Check# Z SS 1 p Received By: �` -- <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />