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i � r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> [5 CCQ56(Y-/ (7 <br /> OWNER/OPERATOR <br /> G & L Ranch LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Scannavino Property <br /> SITE ADDRESS 3650 N Overhiser Road Stockton 95215 <br /> Street Number Dlre0on Street ame CIty Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 5463 Cherokee Road <br /> Street Number Street N.m. <br /> CITY Stockton STATE CA LP 95215 <br /> PHONE#1 Exr. APN# CISI LAND USE APPLICATION# <br /> (209) 931-3570 087-W-16 l)A - 08-a036z <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) — _ <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Tamara Woods CHECKO BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex,. <br /> Neil O. Anderson &Associates, Inc. 1 209 367-3701 <br /> HOME or MAILING ADDRESS PAX# <br /> 902 Industrial Way 1209) 369-4228 <br /> CITY Lodi STATE CA LP 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 FE ERAL laws. <br /> L r <br /> )2-1 <br /> APPLICANT'S SIGNATURE: Z DATE: /vLJ <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER OTHER AUTHORIZED AGENT®EnVlronmental Consultant <br /> 1fArruCvvT is not the B/LL/NG PARTY proof of authorization to sign is required Titre <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 al-the same time it is <br /> provided to me or my representative. YME 1 <br /> TYPE OF SERVICE REQUESTED: <br /> --`Surface <br /> �glSubsurface Contamination Report RE( <br /> COMMENTS: I /2/✓/ Iy�e^,�"��,,^//` �1_- ' � �/ D�" — 2 <br /> �(bIIOS 3� SA ENVIRCILIN ONMENT NTT <br /> HATH DEPAKTME� <br /> ACCEPTED BY: o`t v E le A EMPLOYEE#: ^ 3 2- DATE: i, / C4 <br /> ASSIGNED TO: SCO EMPLOYEE#: (02,2-( <br /> IS G�" DATE: / y/ Z-/09- <br /> Date Service Completed (if already completed): SERNCE CODE: 3/S P 1 E: fD3 <br /> Fee Amount: ItZ Ct C-'1.� Amount Paid 16 ,1 �� Payment Date ( D <br /> Payment Type 1 Invoice# Checkp# 2(q�s� ylE(�(�8\' Received By: <br /> EHD 48-02-025 �` tr [ ^'M' • o t 7 L/ r /a ) SR FORM(Golden Rod) <br /> REVISED 11/17/2003 / /f <br />