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r � y <br /> s <br /> SAN.TOAQU1,%.w_'OUN'fy ENVIRONMENTAL K ALTH*../PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �'�-00 1-1c) <br /> LOWNER/OPERATOR Mr. Lout Yang CHECK If BILLING ADDRESS© <br /> FACILITY NAME Yang Property <br /> SITE ADDRESS 2120 E. 13th Street Stockton 95206 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APIN# LAND USE APPLICATION# <br /> (209)463-6809 1 -6216-12 Nf�assiggd / - - yrs) <br /> PHONE#2 EXT' BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Rebecca Haskett 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 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 lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar s,S ATE nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE G DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER THER AUTHORIZED AGENT❑ <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 i5 <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: -75-L-1 r jC C-JF S'L(s3SU 62F-42-e C-o 1-d <br /> COMMENTS: Please review the attached urface Subsurface Contamination Report. Ther1et �f.eyiew fee <br /> of $186 will be attached by Mr. Lout Yang. If you have any questions, ple Inpttpsitate <br /> to call. <br /> Becky <br /> AIS , <br /> APPROVED BY: 6 L_( U F—f EMPLOYEE#: O`I PNVIA <br /> ASSIGNED TO: ESc o7rD EMPLOYEE#: T HIf Zcr fj <br /> Date Service Completed (if already completed): SERVICE CODE: ( 5 P 1 E: �.C3 <br /> Fee Amount: V / (o,�J Amount Paid Ci r Payment Date f( L <br /> Payment Type Invoice# O Check# eceived By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />