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SAN JOAQUIN%pw1JNTY ENVIRONN%ENT.-sL HEALTH D' , RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR Mr. Douglas Talbert <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME San Joaquin Electric <br /> SITE ADDRESS <br /> 2342 N. Teepee Drive Stockton 95205 <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) P.O. Box 30068 <br /> . Street Number Street Name <br /> CITY Stockton STATEi J <br /> CA zIP 95213 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 952-9980 092-210-08 PA-03-561 <br /> PHONE#2 EXT_ BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR David Welch <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 /> 22 Houston Lane (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,Standal'ERATOR/ <br /> and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE:: <br /> PROPERTY/BUSINESS OWNER❑ NANAGER ❑ OTHERAIJTHORIZEDAGENT® Consultant <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title Eo <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property loc Ihev <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessmek0.) 2pp4 <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same int �+ <br /> provided to me or my representative. utA" <br /> v1N G4 N- <br /> TYPE OF SERVICE REQUESTED: til l y-?�- -F-F- c A()( iJ(j S j 2c c� �P EN�� -30 ) jMEN� <br /> COMMENTS: <br /> Please review the attached SS/NLS. A report review fee of$465 is a <br /> �11-2w6/Z,/d <br /> any qu stigns, please do not hesitate to call. Dave <br /> Y 'i <br /> MAR 2 3 2004 <br /> ENVIRONMENT HE=ALTH <br /> APPROVED BY: F//JJ� V / EMPLOYEE#: 032-1 <br /> ^�J2-f <br /> ASSIGNED TO: v/`) S EMPLOYEE#: ICJ�rL CT DATE: Z-3/ G <br /> Date Service Completed (if already completed): SERVICE CODE: / s--�SS P I <br /> Fee Amount: c(�s Ur,� Amount Paid <br /> Payment Date <br /> Payment Type ✓ Invoice# Check# R9-q-� Received By: � <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />