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SAN JOAQUI' 70UNTY ENIVIRONMENTAL HEALTH ?PARTMENT <br /> .� SERVICE ::I QUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> X200 417161 <br /> OWNER/OPERATOR <br /> Mr. Russel Reece CHECK If BILLING ADDRESS <br /> FACILITY NAME Reece Property <br /> SITE ADDRESS 30850 S. Ahern Road 14" 3 5 Tracy 95304 <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Addes <br /> cfo �verett Wheelock 546 La Contenta <br /> Street Number Street Name <br /> CITY Manteca STATE CA Zip95337 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# j <br /> ( 955)422-1152 255-320-02 - <br /> PHONE#2 EXT. BOS DISTRICTr LOCATION CODE <br /> ( ) /l qq <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco 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 /> CIT` 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. <br /> APPLICANT'S SIGNATURE: Neil o.Anderson s Associates,Inc. DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTO Consultant <br /> If APPLICANT 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: �2n r o- � P <br /> COMMENTS: <br /> Please review the attached Surface Subsurface Contamination Report. If you have'i <br /> questions, please do not hesitate to call. 7 p05 <br /> 7� W11A N�+tr;Q�I�O�����. —�D>�S-Z�- Abby <br /> ��i°, oP°�� EN�P�ciC <br /> 3 Q -PN J ko <br /> APPROVED BY: EMPLOYEE#: C n DATE: N <br /> ASSIGNED TO: EMPLOYEE#: t / DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: T1 P 1 E: A; <br /> Fee Amount: ( Amount Paid I g't Payment Date <br /> Payment Type Invoice# Check# ' (�"q Z Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />