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SAN JOAQUIr —OUNTY ENVIRONMENTAL HEALTH 'PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S,eoo�lo R <br /> OWNER I OPERATOR <br /> Mr. Richard GreenUFNINAL CHECK if BILLING ADDRESS® <br /> FACILITY NAME Green Property <br /> SITE ADDRESS 30400 E. Lone Tree Road Oakdale 95320 <br /> Sbeal Number I cio St Name city ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Addregsl Danielle Denczek P.O. Box 515 <br /> CSO' Street Number treat Name <br /> CITY Escalon STATE CA Zip 95320 <br /> PHONE#1 ErT' APN# LAND USE APPLICATION# <br /> (209)847-4146 229-140-11 ""kinad -P�A <br /> PHONE#I En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ev' <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 ication end that a work t e erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand ds,S A6G an FED IS <br /> APPLICANT'S SIGNATURE DATE: Y ' S d S <br /> PROPERTY/BUSINESS OWN ER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> IrAPPLICANT 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 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: S S w L c .�-2 d G <br /> COMMENTS: Please review the atthed Surface Subsurface Contamination Report. a Jny <br /> ,r estions, please do pot hesitate to call. x h <br /> 7I2V5 �vdby , l °�� <br /> QQ� ONO,Ex���� <br /> APPROVED BY ^ EMPLOYEE M C' P 2 O <br /> ASSIGNED TO: '(/ .-2 EMPLOYEE M <br /> Date Service Completed (if already completed): SERVICE CODE: J P I E: <br /> Fee Amount: 3 Amount Paid f7 D Payment Date �5 05 <br /> Payment Type ,/ Invoice# Check# g�l ecei ed By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />