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SAN JOAQUI`oCOUNTY ENVIRONMENTAL HEALTH SteaeiPARTM ENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# s"Niz;�z OWNER/OPERATOR CHECK If BILLING ADDRE55O Mr- Stan Robertson FACILITY NAME 8224 West Linne Road Propedy SITE ADDRESS 8224W Linne Road Tract/ 95304 Street Number Dir c to Street Name CIN 23D Code HOME or MAILING ADDRESS (If Different from Site Address) 27337 South Banta Road Street Number Street Name CITY STATE ZIP Tracy CA 95376 PHONE#1 fir' APN# LAND USE APPLICATION# I 1 253-220-29 30 31 & 36 PA-04-293 L fi PHONE#2 S DISTi.:. '_OCATION CODE l 1 CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK N BILLING ADDRESS Dave WpIrh BUSINESS NAME PHONE# En. Ne 10 Anderson and Assonate,.;, Inc (20A)."IR7-3701 HOME Or MAILING ADDRESS FAX# 902 Industrial Way 12091369-4228 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Stan TATE and FEDERAL laws. APPLICANT'S SIGNATU :� _ DATE:-a— CG O N-r PROPERTY/BUSINESSOWNERO OPERATOR/MANAGER O OTHER AUTHORIZED AGENT® Consultant?PN IfAPPLIcANT is not the BILLING PARTY proof of authorization to sign is required Tine AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property locate2��5 above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site�sCe§'snT .I,i information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same 6 ��GQUN provided to me or my representative. SAN J ppNMFSTM TYPE OF SERVICE REQUESTED: SOIL- COMMENTS: OILCOMMENTS: Please review the following Soil Suitability Study. We have attach the service review fee of $186. If you have any questions pleas ca . i2 v/'yGp S .f Tall� APPROVED BY: EMPLOYEE#: O > DATE: y CP OS ASsIGNEOTO: O�-t�� EMPLOYEE#: �.t / DATE: / e's Date Service Completed (if already completed): SERVICE CODE: _5 ,> PIE:zG,& Fee Amount: ,p C Amount Paid t IO b.a D Payment Date Payment Type •/� Invoice# Check# 1-75M Received By: EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02