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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR t CHECK If BILLING ADDRESS® <br /> FACILITY NAME Bates Parcel <br /> SITE A2s�9 / 231 N. / E. St. Rt. 99 Frontage/ Spiess Road Acampo 95220 <br /> treat Numbar Hon veer N 01 Zi C e <br /> HOME or MAILING ADDRESS (N Different from She Address) <br /> Street Number - Sheat Name <br /> CITY STATE ZIP <br /> C.4 �1SZS <br /> PHONE#tExt. APN# LAND USE APPLICATION# <br /> (`C9 ) 1t7-6 -oq7c> 7- 005-090-68 & 005-350-11 Unassigned <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> 1 ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Tina Cheney CHECK If BILLING ADDRESS <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: 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 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 /> 61--,� <br /> APPLICANT'S SIGNATURE: �--� C-- C ( — DATE: <br /> PROPERTY/BUSINESSOWNERO OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT I9 �N Gra� E4CL <br /> IfAPPLICANT 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 COLRJTY 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: <br /> COMMENTS: � 3��/t^.0 _ VIP[) <br /> .moi FEB 1 <br /> 7 2u(i6 <br /> JO <br /> HEALTH RO PgEq UN <br /> Ty <br /> BY: EMPLOYEE#: �zpb <br /> / DATE: <br /> T✓-V <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (h already completed): SERVICE CODE: 2 It S P 1 E:Z <br /> Fee Amount: CC> Amount Paid ` 6- 0(J Payment Date AtOI106 <br /> Payment Type 111L"—Invoice# Check# \ 3 3 Received By:N Cf <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />