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SAN JOAQUIN/'7UNTY ENVIROr RENTAL HEALTH T 'ARTMENT <br /> SERVICE T-QUEST <br /> Type of Business or Property FACILITY tt)# SERVICE REQUEST# <br /> OWNER OPERATOR Mr. Lloyd St. Mary CHECK If BILLING ADDRESS® <br /> FACILITY NAME St. Mary Property <br /> SITE ADDRESS 423 S. Fresno Ave. Stockton 95203 <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 9462 Snow Creek Cir. <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95212 <br /> PHONE#t En. APN# LAND USE APPLICATION# <br /> (209)952-7397 145-140-07 W ig a 9 s ejFee* PA--M7- 55 <br /> PHONE#2 En. SOS DISTRICT i LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <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 /> 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 SIGNATURE: �� DATE: <br /> PROPERTY/BUSINESS OWNER❑ L 'ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> I,fAPPLICANT 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: �T— <br /> COMMENTS: PA <br /> of=- i-r RECEIVED <br /> /V)• F &s6077E) qPR 5 2005 <br /> � e <br /> SAN JOAQUIN COUNTY <br /> APPROVED BY: D L(uF_I pe--,4 EMPLOYEE M O3 24 H AV:CET SO <br /> . S` <br /> ASSIGNED TO: F7 S LOTM EMPLOYEE#: S°r It 1 DATE: 7t( S`(a f <br /> Date Service Completed (if already completed): SERVICE CODE: IS P I E: <br /> Fee Amount I g-,(o, 0 ) 1 <br /> Amount Paid p,"D Payment Date <br /> Payment Type L.�'t7t� Invoice# Check# Received By: ,L- <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />