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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 6(� <br /> OWNER/OPERATOR Rosario Costilla CHECK If BILLING ADDRESS® <br /> FACILITY NAME <br /> SREADDREss2514 E. Juliet Road Stockton 95205 <br /> S"M N Do.cli n heel Name CIN Zip Cod <br /> HOME or MAULING ADDRESS (If Different from Site Address) <br /> Sheet Number Sheel Name <br /> CITY STATE ZIP <br /> PHONE#1 Ear. APN i LAND USE APPLICATION# <br /> ( 209) 403-0264 173-040-40 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> I ) i I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R.EQUESTOR <br /> Tina Cheney CHECK N BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ear. <br /> Neil O. Anderson 8l 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 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. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER Q OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> IjAPPLicAN is not the BILLING PARTY proof ojauthorizadon 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 enviromnental/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. <br /> TYPE OF SERVICE REQUESTED: a Y <br /> COMMENTS: s S I µu it/r/OG (Sorn�al t5 <br /> MAY 2 6 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): unt Paid SERVICE CODE: 77 t�� P I E: b <br /> Fee Amount: ` 4J' AmoPayment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />