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SAN JOAQUIl."'OUNTY ENVIR�INMENTAL HEALTH APARTMENT <br /> SERVIC VEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 52o o q coo r <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Armondo Huerta c/o Fred C. Ingalls, PLS <br /> FACILITY NAME <br /> dUpitaProperty <br /> SITE ADD 11255& 515 ENorman Avenue Stockton 95215 <br /> reel Number Direction Street Name city Zio Code <br /> HOME or ING ADDRESS (If Different from Site Address) 4045 Coronado Avenue <br /> Street Number Street Name <br /> `p CITY Stockton STATE ZIP <br /> CA 95204 <br /> PHONE#1 EXT. API# LAND USE APPLICATION# <br /> ( ) 103-280-12 & -13 Prepared in advance of PA No. <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRES <br /> BUSINESS NAME PHONE# EXT. <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 t 's application a d that th work to performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar ,STATE and DERAL ws. <br /> APPLICANT'S SIGNATURE: DATE: O <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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: 1 <br /> COMMENTS: Nv <br /> J, ^GCj <br /> 3N.,OPOvt,M�Nj PES <br /> SP ENvtPO p FLIM <br /> OE <br /> ACCEPTED BY: EMPLOYEE#: D a <br /> ASSIGNED TO: EMPLOYEE#: G DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid Payment Date B <br /> Payment Type Invoice# Check# R ceive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />