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SAN JOAQUIrV "OUNTY ENVIFANMFNTAL HEALTH 1-- ARTMENT <br /> SERVICE REQUEST 1.04 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST; <br /> '510,00 <br /> Z �,64:7- <br /> OWNER/OPERATORRobert Caffese/Ernest Vasti CHECK if BILLING ADDRESS <br /> FACILITY NAME Ligurian Village Subdivision 0 <br /> SITE ADDRESS 5055 E. Main Street Stockton 95215 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6464 Live Oak <br /> Street Number tree!Name <br /> CITY Lodi STATE CA ZIP 95240 <br /> PHONE#1 Ev. APN# LAND USE APPLICATION# Qpnn <br /> (209)463-1869 (Robert Caffese) 159-100-0T,-Qa..09,-10,-11,159-400-2s I /4 Y rJ ^ 169 <br /> PHONE Ev. BOS DISTPICT LOCATION CODE <br /> I ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ' <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: 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 chpordyanwith <br /> ed 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 C11 Q all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE�Ird— e!�� DATE: 2-- D S <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> IJAPPLICANT is rot the BILLING PARTY proof Of authorization to sign is required Title <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 DEPARTMFNT as soon as It is available ar(m "Vme it's <br /> provided to me or my representative. RECEIVED <br /> TYPE OF SERVICE REQUESTED: Review Surface andSubsurfaceContamination Report <br /> COMMENTS: 111,41o5 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> —APPROVED SY: S EMPLOYEE#Z DATE: Z/J <br /> ASSIGNED TO: EMPLOYEE <br /> ate Service Co ed life y completed): SERVICE CODE: P I E: <br /> Fee Amou : $/406. 0- 1 Amount Paid �0 7 D p Payment Date <br /> Payment Type ,�..�rri1 nn Invoice,# Check# 3b� Received By: <br /> EH048-O7-025 ( U40E-f'A e-) ( 1 x '1 0-J SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />