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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> pa -�-l7-9 ,' <br /> OWNER/OPERATOR <br /> Michele Hackett CHECK If BILLING ADDRESS® <br /> FACILITY NAME <br /> SITE ADDRESS41 00 & 4108 W. Riviera Drive Stockton 95204 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 127 Echo Place <br /> Street Number Street Name <br /> CITY Discovery Bay, CA 94514 STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 510)724-3388 x 204 109-040-20, -21 "_07000 S7.S(om) <br /> PHONE#2 E%T. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Tamara Woods <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Neil O. Anderson & Associates Inc. 209 1 367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209 )369-4228 <br /> CITY Lodi STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: 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 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 /> 1 <br /> APPLICANT'S SIGNATURE: 4 C� DATE: <br /> PROPERTY/BUSINESS OWNEROPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPL/CANT 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: PAYMENT <br /> COMMENTS: j� / � / `� <br /> HECEIVED <br /> d li�v d ars' � <br /> JUL 1 3 2007 <br /> / SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DE <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: / EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed: SERVICE CODE: P i E: <br /> Fee Amount: / U4' Amount Paid �s F1 Payment Date <br /> Payment Type ;, ` Invoice# Check# - Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />