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SAN JOAQUIN COUNTY ENV;RONNil NTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Vacant Land t/ <br /> OWNER/OPERATOR <br /> Affordable Luxury Homes CHECK if BILLING ADDRESS® <br /> FACILITY NAME Guernsey Avenue <br /> SITE ADDRESS 3902 & 3924Guernsey Ave Stockton 95215 <br /> Street Number DI Hon Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> c/o Wong Engineers Inc. Street 45Z8ber I Feather RiverreDr. Ste. A <br /> CITY Stockton STATE CA ZIP 95219 <br /> PHONE#1 Ext' APN# LAND USE APPLICATION# <br /> 1209) 477-7563 157-140-17 &53 titTassigneel f D(< //�15r� <br /> PHONE#2 EXT. LOCATION CODE <br /> (209 ) 476-0011 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Abby Racco <br /> CHECK It 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 )333-8303 <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. ��T <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with al <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: capj'Q..4/ DATE: G-lq.ugk tAM 2 0 2004 <br /> PROPERTY/BUSINESS OWNERO IF <br /> OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Consultant e, IoAa0IN cOUNTY <br /> TAL <br /> /f APPLICANT is not the B/CLING PARTY proof of authorization to sign is required Title E`TH DEPARTMENT <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the properol&aced 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 CoUNCY 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: n1U/L�— <br /> COMMENTS: Please review the attached Surfce/Subsurface Contamination Report. Wong Engineers will <br /> submit the $186 report review fee. If have any questions, please do not hesitate to call. <br /> 3/ic/ate �ZD d/O 0 Abby <br /> APPROVED BY: L-( L;ChrD�-` EMPLOYEE#: J3 Z,/ DATE: 5- <br /> 2G <br /> ASSIGNED TO: F S C C rl l `� EMPLOYEE#: SF L DATE. - <br /> Date Service Completed (if already completed): SERVICE CODE: 3 /S' PI z(o. G_S <br /> Fee Amount: Amount Paid ,� Payment Date --oD `{ <br /> PaymentType ✓ Invoice# Check# g"j`� Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 8-5-02 <br />