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SAN JOAQU" COUNTY ENVIRQNMENTAL HEALTF-nfPARTMENT <br /> `+' SERVICE REQUEST "`4 <br /> Type of Business or Property FACILITY ID# F <br /> REQUEST# <br /> S2oo N �27 a3 <br /> OWNER/OPERATOR <br /> Donald Conti CHECK if BILLING ADDRESS® <br /> FACILITY NAME Newton Road Mini-Storage <br /> SITE ADDRESS 3827 N. Newton Road Stockton 95205 <br /> Street Number Direction Street Name CI Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> c/o Associated Engineering Group,4206 Technology Dr. <br /> Street Number Street Name <br /> CITY Modesto STATE CA Zip 95356 <br /> PHONE 11T APN# LAND USE APPLICATION# <br /> (209)545-3390 132-070-09 PA-04-768 <br /> PHONE 12 ExI. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK It BILLING ADORES51:1 <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 zap 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 d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE an4'FEDERALj,laws. <br /> ,fekCAS <br /> IM <br /> APPLICANT'S SIGNA URE: p,MD 'Aa( Tey (oI i I0S <br /> PROPERTY/BUSINESS OWNER OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENTtZ 4:4CW- .S C0NSULTA,-rr <br /> I,fAPPLICANT is not the BILLING P R proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEA E INFO ION: 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 environmentaUsite 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: 4' `i N� , l ,t I .+-y 1-'k L V iA L IS. <br /> COMMENTS: 5?//3/G51 SECT liy p <br /> G C <br /> M � io 14 2o05 <br /> SAN JOAQUIN COUNTY <br /> N\IIRQNMENYAL._ <br /> APPROVED EMPLOYEE#: 61 DATE" TN <br /> ASSIGNED T 7 \ 1. ' - EMPLOYEE#: (� DATE: <br /> Date Servie c pletecl (If already completed): SERVICE CODE: — ,L� PIE: a <br /> Fee Amount: Amount Paid Payment Date b aS <br /> Payment Type ✓ Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />