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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> U <br /> OWNER/OPERATOR Mrs. Jo Moore CHECK If BILLING ADDRESS® <br /> FACILITY NAME Moore Property q 5 v,l <br /> SITE ADDRESS 11040 E. I Mariposa Road Stockton 95336 <br /> street Number t e DIN ZIP Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number street Name <br /> CITY STATE ZIP <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (209)463-3641 181-060-15 PA- 05-252 <br /> PHONE 92 Exr. SOS DISTRICT !" LOCATION Cyp <br /> I 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Nancy R. Kramer CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# En. <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,Standards,STATE and FEDERAL laws. QQ <br /> APPLICANT'S SIGNATURE: DATE: .d.P� DD6 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MA ER ❑ OTHER AUTHORIZED AGENT❑'f <br /> IfAPPLICANT is not the BILL/NG PAR 7Y proof of authorization to sign is required rine <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. p <br /> TIDE OF SERVICE REQUESTED: SOII Suitability StUdy i C£ lU7 <br /> COMMENTS: <br /> ���ne..t�✓� SSFP 1 8 Zoos <br /> Iq ` e eG o Ei v/j Ulu coir, <br /> yEACTII oFP48 AL <br /> APPROVED BY: 4 i EMPLOYEE#: ei y C, DATE: q B <br /> ASSIGNED TO: GG �4 EMPLOYEE#: 55/r DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 'j 22 P 1 E: Z6U <br /> Fee Amount: 4 0. 00 Amount Paid Payment Date q -' <br /> Payment Type Invoice# Check It Received y: Vq-r,- <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />