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SAN JOAQUIN COUNTY ENVI'OPIlN NTALHEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# S200y/yS OWNER/OPERATOR Mr. Julio Lucas CHECK if BILLING ADDRESS® FACILITY NAME Lucas Property SITE ADDRESS 3 opp Stockton 95205 3666 andSV�[Number Fa Miner Street Name CRY 1 23D Code HOME Or MAILING ADDRESS (If Different from Site Address) 1529 Rose Garden Ct. Street Number Street INIarea CITY Modesto STATE CA Zip 95356 PHONE#1 Exr. APN# LAND USE APPLICATION# (408)910-8460 143-350-19,20 &21 Unassigned PHONE#2T• SOS DISTRICT LOCATION CODE (888)210-5100 CONTRACTOR/ SERVICE REQUESTOR REQUESTOR Nancy Rosulek CHECK It BILLING ADDRESS BUSINESS NAME PHONE# E[r. Neil O. Anderson &Associates Inc. 1209 367-3701 HOME Or MAILING ADDRESS FAX# 902 Industrial Way (209 )369-4228 CITY Lodi STATE CA Zip 95240 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this app Cation and that the wort a performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,. ATE a FEDERAL lay . APPLICANT'S SIGNATURE• DATE: PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ 1fAPPL/c4NT is nt rhe BiLmNG PARTY.proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: S''U e-FA C-OF— S`�Lt-t3d''�-L�-F°4LE- Cb^QTR�i.��7 U"J i�-�'a�T COMMENTS: Please review the attached Surface Subsurface Cqntamination R ort. If you have N questions, please do not hesitate to call. Db D-�, L, F?EI Iz�u YMA Nancy v,o If,, 8 MPR 11 �50 l �. 30 0 k MENS APPROVED BY: 01, t UE4 ter.(— EMPLOYEE#: [� 3�1 DATE: 3 -t HpEP ASSIGNED TO: •E S C o7TZ0 EMPLOYEE#: S14(11 DATE: Date Service Completed (if already Completed): SERVICE CODE: 1 PIE: �(o• ^' Fee Amount: W&' C'D Amount Paid DPayment Date 3(-7 1 O S Payment Type ✓ Invoice# Check# r'`"'� a (j 23 Received By: EHD 46-01-025 SERVICE REQUEST FORM REVISED 6-5-02