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SAN JOAQU**OC–OUNTY ENVIRONMENTAL HEALTR145tPARTMENT <br /> SERVICE,REOIJEST <br /> Type of-gusiness or Property FACILITY ID# SERVICE REQUEST# <br /> ( Lo-�6 <br /> OWNER/OPERATOR <br /> Ms. Jo Moore CHECK If BILLING ADDRESS® <br /> FACILITY NAME Moore Property <br /> SITE ADDRESS 11040 E. Mari osa Road <br /> P Stockton 95336 <br /> Street Number Traction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS if Different from Site Address) <br /> Sheet Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Etr' APN# LAND USE APPLICATION# <br /> (209)463-3641 181-060-15 Unassigned -AS Z� /t1 J <br /> PHONE 92 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <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 FEDE ws <br /> APPLICANT'S SIGNATURE ,it,�,, DATEEP 4�7 Ti 01'}— <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAP AGER ❑ OTHER AUTHORIZED AGENT;9 <br /> I,fAPPLICANT 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 JOAQL5N 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: K 2-F C2 s'LI r(G a <br /> COMMENTS: <br /> V <br /> AP2 2 <br /> API? <br /> /Ai/.F. ��Til" ��A 20p5 <br /> ( qiil CJD 0 <br /> EP <br /> APPROVED BY: - EMPLOYEE#: DATE: <br /> ASSIGNED TO. EMPLOYEE#: �.1 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: - 0 <br /> Fee Amount: ItAmount Paid Payment Date a 9 <br /> Payment Type ✓ Invoice# Check# ' f �' Rec ived By: <br /> JV <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />