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SAN JOAQIXOUNTY ENVIRONMF VTAL HEALTI PARTMENT <br /> SERVICE 1REQCfEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F � 5R 0o 4S'7 <br /> OWNER/OPERATOR <br /> Alex Toccoli gz I Is F1 CHECK if BILLING ADDRESS O <br /> FACILITY NAME <br /> SITE ADDRESS 333 S. Hewitt Road Linden <br /> Street Number Direction Street Name I city zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 165 W. Cleveland Street, Suite 3 <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95204 <br /> PHONE#1 EXT. APN if LAND USE APPLICATION# <br /> ( 209) 639-7605 183-320-17 PA-05-050 <br /> PHONE#2 En. BOIS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR Dave Welch CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# E`T. <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,StandMdsSandFEDERAL laws.APPLICANT'S SIGNATURE: " /i/ DATE: 7/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® L U ov <br /> IfAPPLicANT is not the BILL/NG PARTY proof of authorization to sign is required Title <br /> AUTHORIZATIO T INFORMATION: When applicable,I,the owner or operator of the property located at the <br /> above s ;-h relit' authrf ze the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUN ry ENvIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. L� <br /> TYPE OF SERVICE REQUESTED: S a r L 'tip'►r' Se C-[ T� l T <br /> COMMENTS: Expedite Review of Soil Suitability Study, $372.00 enclosed. FIEG�\ <br /> i,�i�/es a 200 <br /> �y 7 lt�J� t��36 6 NQV Tv <br /> /21- fa3CCT/UGo <br /> AQUtN tdt <br /> HHS 7 <br /> ��Zb M•d� <br /> APPROVED BY: O L-L Li.fit V24 <br /> EMPLOYEE#: Q 3.:;t/ DATE: <br /> ASSIGNED TO: rn, -SC,07M I <br /> EMPLOYEE#: Q�/f� DATE: <br /> Date Service Completed (N already completed): SERVICE CODE: Z P I E: <br /> Fee Amount: s� 72.ov Amount Paid 7 t,V Payment Date I 0 <br /> Payment Type L,,-� Invoice# Check# g9� Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />