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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5i�L C' s <br /> OWNER/OPERATOR <br /> Thelma E. Hieb Revocable Trust c/o David Hieb CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 10940 E. Harney Lane Lodi 95240 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4325Driftwood Place <br /> Street Number Street Name <br /> CITY Discovery Bay STATE CA ZIP 94505 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( 209) 521-8986 063-180-02 <br /> PHONE#Z Ext. BOS DISTRICT -7LOCATIO O <br /> ( 925) 437-9040 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Tina Cheney 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 thitthe work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL,laws.p nn <br /> APPLICANT'S SIGNATURE: ���/ ` DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OT ER AUTHORIZED AGENT <br /> If APPL/CANT 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: L <br /> COMMENTS: ,9 E C E I V E <br /> 5 78 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> APPROVED BY: EMPLOYEE#: DATE. <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount ( v Amount Paid D Payment Date I11 <br /> Payment Type Invoice# Check# 7S Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />