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SA14JOAQUIN COUNTY'ENVIRONMENTAL HEALTH DEPARTMENT' <br /> SERVICE REQUEST SERVICE REQUEST# <br /> FACILITY ID# <br /> Type of Business or Property <br /> I c--CHECK If BILLING ADDRESS <br /> OWNER OPERATOR Mario Serrano <br /> FACNTT NAME Serrano Parcel <br /> Stockton 95215 <br /> SITE ADDRESS 4310 S. State Route 99 E. Frontage Rd. CI Zi Cede <br /> Street Number Direction <br /> Street Nama <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Street NuStreet Name <br /> Number STATE ZIP <br /> CITY <br /> ExT. APN# LAND USE APPLICATION# <br /> PHONE#1 179-172-35 PA-03-52 <br /> (209 ) 345-4171 BO6 DISTRICT LOCATION CODE <br /> PHONE#2 EXT. <br /> CONTRACTOR It SERVICE REQUESTOR <br /> CHECK If BILLING ADDRESS® <br /> EREQUESTOR Abby RaccoExr. <br /> PHONE#Neil OAnderson & Associates Inc. 209 367-3701 <br /> FAX# <br /> G ADDRESS (209)333-8303 <br /> 902 Industrial Wa STATE CA ZIP 95240 <br /> Lodi <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 1 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, and FE L laws. <br /> APPLICANT'S SIGNATURE: DATE: tQ 410LL <br /> PROPERTY/BUSINESS OWNER 13 OPERA OR/MANAGER ❑ OTHER AUTHORIZED AGENT® Consultant <br /> IfAPPttCANT 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: t <br /> COMMENTS: Please review the attached Soil Suitability Study. The report review fga0VL *attached. <br /> If you have any questions, please do not hesitate to Call.�rAbby q�RECEIVED <br /> y,� '/, a" '13',7 JUN <br /> v 4 2304 <br /> APPROVED BY: (�Ll V Et 1eJ4 EMPLOYEE : 2 EN IRAI6IAA T (J <br /> ASSIGNED TO: EMPLOYEE#: DATE U tL <br /> Date Service Completed lit already completed : SERVICE CODE: 5a� PIE: l <br /> Fee Amount: r Qa Amount Paid J<Z leePayment Date <br /> Payment Type Invoice# Check#J Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />