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SAN JOAQU�;OUNTY ENVt.-,ENS AL HEALTH APARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5/,�_Or9� <br /> OWNER/OPERATOR <br /> Longstreth Family Limited Partnership CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME Longstreth Parcel <br /> SITE ADDRESS 17336 E. Sola Rd. Collegeville 95215 <br /> Street Number Direction Street Name Citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> c/o Robert Braden Consulting2��0 Standiford Avenue <br /> Stree umber Street Name <br /> c'TY Modesto STATE CA ZIP 95350 <br /> PHONE#1 EXT. APN# LAND USE APPLICATIONA <br /> (209 ) 531-6959 183-120-05 Unassigned0 sJ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco 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 )333-8303 <br /> CITY Lodi STATE CA Z'P 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 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. 00__ n <br /> APPLICANT'S SIGNATURE: aC 4 16- �VL�X�Y�Ujn fi 4f0,-_• DATE: <br /> PROPERTY/BUSINESS OWNER OPLTOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Consultant <br /> If APPLICANT is not the BILLING PARTY proof of autlioriZation 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: �� C(Jn t <br /> COMMENTS: Please review the attached Surface/Subsurface Contamination Report. The report_rev�,P, \N <br /> fee of $186 is attached. If you have any questions, please do not hesitate to call. Abt�EIVE <br /> 5 2004 <br /> P RI lip! UNTY <br /> APPROVED BY: / / EMPLOYEE#: — (JC� <br /> d _l DATE: JN Jul—MEN ALyINENT <br /> ASSIGNED TO: EMPLOYEE#: �G/l�(� DATE: <br /> Date Service Completed (if already completed): SERVICE tCODIE: P I E: �3 <br /> Fee Amount: Amount Paid A �wil D O Payment Date <br /> Payment Type ✓ Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />