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SANJOAQUi- IUNTYENVIRONMENTAL HEALTH , ARTMENT <br /> SERVICC REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR Alan Hofmann, Bryan Hofmann, and San Neilsen CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Hofmann Property <br /> SITEADDRM%20 / 30972 1 East Lone Tree Road Oakdale 95361 <br /> S Street N-, stn.o Name CiN Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site A d s <br /> c�orF�I& Hofmann 9091 North WtN... n Drive !f`vffl <br /> treat Number Street Nama <br /> CITY Fresno $TATE 930 <br /> (LA <br /> PRONE#t En' APN!/ LAND USE APPLICATION# <br /> (559)269-2419 229-150-01 / 229-150-03 Unassigned <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Crystal Spurr CHECK If BILLING ADDRESSEI <br /> BUSINESS NAME PHONE# En. <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209 )369-4228 <br /> CITY Lodi STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business ow�T` op r paTi� agent of same, <br /> acknowledge that all site and/Or project specific ENVIRONMENTAL HEALTH DEPARTM 11h0 y C 3 po) gTed with this project <br /> or activity will be billed to me or my business as identified on this form. I J ISI <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �1y,.y �., _Neil 0.Andemon&Associates,Inc. DATE: -AGdS <br /> PROPERTY/BUSINESS OWNER[3 OPE ATOR/MANAGER ❑ OTHERA(ITHORIZED AGENT 0 Consultant <br /> f.a PPLICANT is not the BILLLVC PARTY,proof OJ authorization to sign Is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It i5 available and at the same time it is <br /> provided to me or my representative. p <br /> TYPE OF SERVICE REQUESTED: Surface& Subsurface Contamination Report A�,,M 0 <br /> COMMENTS: <br /> e✓l�ttJ ',�- �a..�'9 ����',,, ;, � PPR 2 9 o�NJTv <br /> APPROVED BY: L; CI b( tC'..,q EMPLOYEE#: C252- DATE: 14 hG/ G� <br /> ASSIGNED TO: i$�ctTrz EMPLOYEE#: 'Wtt / DATE: "i 11 <br /> Date Service Completed (if already completed): SERVICE CODE: 2 PIE: <br /> Fee Amount:. I Q(u.s: AmountPaid Payment Date <br /> PaymentType Invoice <br /> d#rAa� Check# Received By: <br /> END 4&01-025 SERVICE REQUEST FORM <br /> REVISED 0-5-02 <br />