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SAN JOAQL' —OUN7 Y ENVIRONi\IENTAL HEALTI 7PARTMENT <br /> ~ SERVICE -.%I:QIIEST ~ <br /> Type of Business or Property FHC!LITY ID# SERVICE REQUEST# <br /> S2o0 4171(a <br /> OWNER/OPERATOR <br /> Mr. Russel Reece CHECK If BILLING ADDRESS <br /> FACILITY NAME Reece Property <br /> SITE ADDRESS 30850 S. Ahern Road l k,-� -2 Tracy 95304 <br /> rec <br /> Street Number Dition Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Add es <br /> M' Everett Wheelock546 La Contenta <br /> er <br /> Street NumbStreet Name <br /> CITY Manteca STATE CA Zip95337 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# �/I <br /> ( 955)422-1152 255-320-02 / (� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Abby Racco <br /> CHECK If BILLING ADDRESS <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 /> 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 /> 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: Neil o.Ande-son s Associates,Inc. DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT R] Consultant <br /> IfAPPLLCANT 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: ? l� '� P21' <br /> COMMENTS: Report. <br /> Please review the attached Surface Subsurface Contamination If you have <br /> C( questions, please/do not hesitate to call. <br /> l' i ( . .�' —3 V 1^/t ^,C�;s t Abby y� ._ �,t .�cJ, ;��N�, GO <br /> fO�C1U� ENj PSN <br /> APPROVED BY: EtAPLOYEE#: (, G DATE: <br /> ASSIGNED TO: ` f� I� � EMPLOYEE#: "�I(,I( DATE: / F� <br /> k!l 171 <br /> Date Service Completed (if already completed): SERVICE CODE: A'�"11 � P I E: -L' <br /> Fee Amount: Amount Paid I S'� Payment Date 3 CI p S <br /> Payment Type ✓ Invoice# Check# I (� Z Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />