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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 gesso© y_s <br /> OWNER/OPERATOR <br /> Gabriel Manzo c/o Art Matedne CHECK If BILLING ADDRESS® <br /> FACILITY NAME <br /> SITE ADDRESS 2002 13th Street Stockton 95206 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P.O. Box 505 <br /> Street Number Street Name <br /> CITY Stockton CA STATE ZIP 95201 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209)649-2201 171-200-36 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Tina Cheney 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 ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized of of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated wt is 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: C �� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /f APPL/CANT 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: G Y N1 ENZ._ <br /> COMMENTS: f <br /> MAR 2 1 2001 <br /> SAENVI <br /> ENVIRONMENTAL <br /> �ANN <br /> T l7FPA TMENT <br /> APPROVED BY: n ' EMPLOYEE#: /� DATE6L : 3 0 7 <br /> ASSIGNED TO: '� /.}-��t j) EMPLOYEE#: tF/ y DATE: <br /> Date Service Completed (if already coom leted): SERVICE CODE: 3/_5 P i E. O <br /> Fee Amount: U Amount Paid TTP c U Payment Date <br /> Payment Type Invoice# Check# Received By: SLG <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />