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......... �-- <br /> aAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR Joe Ratto <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 11981 S. Roberts Road Stockton 95206 <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 2762 Tracy Blvd. <br /> Street Number Street Name <br /> CITY Tracy STATE CA ZIP 95376 <br /> PHONE#1 EXT_ APN# LAND USE APPLICATION# <br /> ( 209) 462-4738 191-150-03 <br /> PHONE#2 EXT. BOS DISTRICT LOCA I,ON CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Tina Cheney CHECK If BILLING ADDRESS El <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 /> Clrr 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 /> 1 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 /> APPLICANT'S SIGNATURE: y DATE: ril 2Z, 2crJC <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAG ❑ OTHER AUTHORIZED AGENT 5,Izzf4 5eeza h 5 6- <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 /> -.M- <br /> COMMENTS: <br /> RLr::-CS' —r-- <br /> --D <br /> SAN JOf1QUIN R'7y COU <br /> ENVIRON COU <br /> t-\ In H <br /> APPROVED BY: EMPLOYEE#: �6 DATE: . <br /> ASSIGNED TO: a EMPLOYEE#: 7 <br /> C DATE: <br /> Date Service Completed (if already completed): C SERVICE CODE: J� P 1 E: G� <br /> Fee Amount: Amount Paid ' bo Payment Date <br /> Payment Type Invoice# Check# 4 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />