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SAN JOAQUI1 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property 5^ IL^5' !D# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Steven Malcoun CHECK If BILLING AODRE55O <br /> FACILITY NAME <br /> SITE ADDRESS 7953 Foppiano Lane Stockton95212 <br /> Street Number Direction Street Name C' Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 5905 Widgeon Court <br /> Street Number StreetName <br /> c'T' Tracy STATE CA ZIP 95207 <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (209 ) 239-4908 086-470-15 PA-03-493 <br /> PHONE#2 En. SOS DISTRICT LGCATIDN Gone <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> David Welch CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# ExT. <br /> Neil O. Anderson & Associates Inc. 209 1 367-3701 <br /> HOME Or MAILING ADDRESS FAx# <br /> 22 Houston Lane ( 209) -4228 <br /> clry Lodi STATE CA z'P 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 ENVIRONNENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this fonn. <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,Standar , STAT <br /> ^E <br /> �a'nd FEDERAL,laws. <br /> APPLICANT'S SIGNATURE � _ Neil o.Anderson&Assoc.Inc. DATE: nPCPmhpr 10, 2003 <br /> PROPENTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ O 1 11 AuTtIORIzLD AGENT® Consultant <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 ENVIRONNIENTAL HEALTU DUPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OFSERVICE REQUESTED: NL'7--.4rt i-oAZ�+ hlG S7-14- <br /> COMMENTS: please review the attached Soil Suitability Study/ Nitrate Loading Study. A report reviewT <br /> fee of$465 is attached. If you have any questions, please do not hesitate to p�dN <br /> DEC 112003 <br /> APPROVED BY: DL EICIPLOYEE O: 0.32( DATE' UN <br /> AN U <br /> ASSIGNED TO: S C.O E'Jw IYE£#: �'O - BATE: E D�dtlEFIT <br /> Date Service Completed (if already completed): SERVICECOD£: S2 S PIE: 2.(0 ,O"L— <br /> Fee Amount: tE(03', a O Amount PaiS 017 Payment Date (>I(( O 3 <br /> Payment Type ,j Invoice# Check# 1cf r�-S3 Received By: <br /> E -05-0 SERVICE REQUEST FORM <br /> REVISEDEVISED 5[2 <br />