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SAN JOAQUP"eOUNTY ENVIRONMENTAL HEALTH ki'tPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> c (OGD 44v <br /> OWNER/OPERATOR <br /> Mr. Keith Watts CHECK If BILLING ADDRESS <br /> FACILITY NAME Wafts Property <br /> SITE ADDRESS 17667 E. Liberty Road <br /> Street Number ir.c tr tNa Galt 95632 <br /> CIIN Zin end, <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> 8100 East Orchard Road o <br /> Street Number Street Name <br /> CITY Acampo STAT6A ZI55220 <br /> PHONE#1 Ei. APN# LAND USE ADO / <br /> ( 1 009-090-08 & 009-080-02 UPn a s s i 6 n e <br /> PHONE ICL Ext. BOS DISTRICT LOCATION CODE <br /> I 1 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR David Welchx❑ <br /> CHECK If BILLING ADDRESS <br /> E] <br /> NAME <br /> PHONE E. <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way12091369-4228 <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 /> 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,Stan ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATU DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Consultant <br /> If.4PPL/CANT is no[the B/LLtNG PARTY proof of authorization f0 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 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. n q <br /> TYPE OF SERVICE REQUESTED: Se t l Su t /74 /�t L .'I S' 1-2't '_1 <br /> _. rr)_ /" KkCL'8,C Lv <br /> COMMENTS: please review the attached SSS. The report review fee of$279VN"e i ached by <br /> our office. If you have any questions, please do not hesitate <br /> to call. 7 2004 <br /> AQURONIMENTALTM <br /> APPROVED BY: GLI VE(Q EMPLOYEE#: 2llE DATE: (2-1716V <br /> ASSIGNED TO: l �Q r N EMPLOYEE#: S'_3��—///� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: SZ-Z_ Z PIE: .2_,�,.D/ <br /> Fee Amount: - /�� Uo J ' S _$[Z SAtftolnt Paid a — Payment Dat `l <br /> Payment Type Invoice# Check# 11A5 3 <br /> Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />