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SAN JOAQuix.. .OUNTY ENVIRONMENTAL HEALTH haIdARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5Izov 36/ 3 <br /> OWNER/OPERATOR <br /> Ronald Robinson CHECK If BILLING ADDRESS <br /> FACILITY NAME Robinson Parcel <br /> SITE ADDRESS Highway 12 U7. Or— Gu��0 West of Lodi 45242 <br /> Street Number I Dir I - Ci i CoEe <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 1108 Riverpointe Dr. <br /> Street Number Street Name <br /> CITY Lodi STATE CA ZIP 95240 <br /> PHONE#1 En. ALU APPLICA�TO <br /> 02 Ur <br /> I I�� <br /> 1209 ) 948-1641 025-060-03 U Y <br /> PHONE#2 EaT. BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EtT. <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 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:���%i'�`-�C� Neil O.Anderson&Associates, Inc. DATE:: <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTO ConSUltant <br /> IfAPPLtcANT is not the BILL/NG 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. 'nC ' <br /> TYPE OF SERVICE REQUESTED: (si �c.L.�O ,.}GF [,Q sFj4L.� 0-00-r0-00-rT I A2-" //., <br /> a,e2T <br /> COMMENTS: please review the attached Surfa a/Subsurface Contamination Report. The rC <br /> fee of 186 is attached. If you have any question , please do not hesitate to ED <br /> 9(Y �° AUG 2 5 2004 <br /> �e <br /> APPROVED BY: Ll us,V—;,4 EMPLOYEE#: O9J Z.I DA NTY <br /> ASSIGNED TO: ��,� G EMPLOYEE#: �i t/. DA G R MENT <br /> Date Service Completed (N already completed): SERVICE CODE: 3l I E: (o,0 <br /> Fee Amount: �- .t>J Amount Paid / Payment Date �� D <br /> Payment Type Invoice# Check# GJ? �-7� Received By: ALle <br /> EHD 48-01-025 P SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />