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SAN JOAQUI?VOCOUNTY ENVIRONMENTAL HEALTH bMPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SQ <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> nolnres; Lim <br /> FACILITY NAME <br /> Lim Pro ert <br /> SITE ADDRESS 23403S Hansen Road Tracv 95304 <br /> Street Number Ore Street Name Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 38746 Cherry Lane <br /> Street Number Street Name <br /> CITY Fremont STATE ZIP <br /> 94536 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (510)714-9327 209-130-29 PA-04-791 (1VIS) <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Nancy Rosulek <br /> BUSINESS NAME PHONE# Exr <br /> Neil 0. Anderson and Associates; Inr 190P)367-3701 <br /> HOME Or MAILING ADDRESS FAX# <br /> 902 Industrial Way ( )369-4228 <br /> CITY Loda <br /> STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 1 have prepared this application d that the wp4 to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE ED RAL la <br /> APPLICANT'S SIGNATURE/ DATE: ')�- "n <br /> O*k5 <br /> PROPERTY/BUSINESS OWNERM/ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> IjAPPUCANT is not the BILLING PAR 7r proof of authorization to sign is required nue <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: o/G su r�c4iG�r sT o :=PAY '-- <br /> COMMENTS:L <br /> AUG 15 2005 <br /> SAN JOAQUIN COUENVIRONMENNTY <br /> AL <br /> HEALTH DEPARTT <br /> NT <br /> APPROVED BY: EMPLOYEE#: LZ// DATE: � 4(r— <br /> ASSIGNED TO: VA') EMPLOYEE#: D D O DATE: �� S <br /> Date Service Completed (if alreadycompleted): SERVICE CODE: 5 PIE <br /> :1/60 <br /> Fee Amount: Amount Paid -"F/�,00 Payment Date ( O <br /> Payment Type ✓ Invoice# Check# (0 � L A yed By: <br /> EHD 48-01-025 AUG i 5 2005 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br /> ENVIRONIMENT HEALTH <br /> PERMIT/SERVICES <br />