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• SAN,JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID If SERVICE REQUEST If <br /> Agriculture <br /> S ,�%'S.3�) 7q <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> Cotta Properties, Inc. <br /> FACILITY NAME 10149, 0301, 10501 N. Peltier Road and <br /> SITE ADDRESS 3850 N Blossom Road Thornton <br /> Street Number Direction <br /> Street Name c1tv Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 10301 W. Peltier Road <br /> Street Number Street Name <br /> CITUSTATE CA ZIP 95242 <br /> Lodi <br /> LAND USE APPLICATION# <br /> PHO{ 369.1119 Ex 11#040-02 -03,-05,-06 <br /> T BOS DISTRICT LOCATON CODE <br /> PHONE#2 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS® <br /> Tamara Woods <br /> PHONE# ExT. <br /> BUSINESS NAME <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 /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN IOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST and Ff DERAL law <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER(, PERATOR/MANAGER 13OTHER AUTHORIZED AGENTAelft4o/. ;'-FYY✓� <br /> tf.4PPLICANT is not the BILLING PAR TP Proof of authorization to sign is required Tine <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: Surface Subsurface Contaminati n Report PA <br /> 1 ' <br /> COMMENTS: <br /> J,S/�'.4� 'i}.�i4 it'4as°cJ /4jD tV '✓1 ^l 'T <br /> Sq^'110 ` 1 l�GB <br /> FiylrlgoUW O <br /> pq <br /> hTH p EryT 'V)Y <br /> APPROVED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: ATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount Amount Paid \ \,�o Payment Date LA <br /> Payment Type ✓ Invoice# Check# Z \` Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />