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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHTIEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# -520o 9(q(S-6 OWNER/OPERATOR Mr. Armando Huerta CHECK If BILLING ADDRESS® FACILITY NAME Huerta Construction SITE ADDRESS t 11573 Norman Avenue Stockton 95215 Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 11923 Norman Avenue Street Number Street Name CITY Stockton STATE CA ZIP 95215 PHONE#t ExT. APN# LAND USE APPLICATION# 64— 05 -21 ( 209) 467-0622 103-280-14 Unassigned 1 PHONE#2 Exr. BOS DISTRICT LOCATION CODE ( ► CONTRACTOR / SERVICE REQUESTOR REQUESTOR Nancy Rosulek CHECK If BILLING ADDRESS BUSINESS NAME PHONE# EXT. Neil O. Anderson & Associates Inc. 209 367-3701 HOME or MAILING ADDRESS FAX# 902 Industrial Way (209 )369-4228 CITY Lodi STATE CA ZIP 95240 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and at the wor to be per rmed will be done in accordance with all SAN JOAQurN COUNTY Ordinance Codes,Standards,. TATE and FEDI RAL laws. APPLICANT'S SIGNATURE: DATE: ( 0 .3 1 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT y't"'lJ M' V t,/✓N�"' If APPLICANT is not the BILLING PARTY,proof of authorization to sign is require r Title2 Ea�iCL AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Surface /�and ,,Subsurface Contamination Report C ^, COMMENTS' `� �Z 7,Oj / t�l/6' 4+0�� d LJ O� O`7`�� N 2 2005 y 'We< ENVIRaNIW&V T ti ti H q PERMITIsE�VC STH Jpll o�N� APPROU �� lJ�t� L EMPLOYEE#: 3� ( DATE: /� ' /C S ASSIG -[ F'�L� S EMPLOYEE#: (�G,>v�l DATE: �C�G;� Date Service Completed (if already completed): SERVICE CODE: [S P/E: � L,3 Fee Amount: ,'U Amount Paidb �� Payment Date �\ 2- � S Payment Type �� Invoice# Check# Received By: 1 - EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02