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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> -;=aHFeII8-Waddell CHECK if BILLING ADDRESS® <br /> FACILITY NAME <br /> SITE ADDRESS 14645 E. Tokay Colony Road Lodi 95240 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# A-1 -e�-e'e age. <br /> (209 ) 663-6244 065-270-02 <br /> PHONE#2 EXT. BOS DISTRICT LOCATIOy-f; E <br /> ( ► G L� <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 Z'P 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, 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, TATE FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �� /1�EJ'o/L� DATE: <br /> PROPERTY/BUSINESS OWNER I OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /f 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: SSt_e A�7 rp__F-Ac-g CO N'T7 A--[ �.nJ <br /> COMMENTS: /e8 2 ZS o� REC v 2F <br /> JAN 2 9 2008 <br /> �/ L- SCr�i "JU <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENT <br /> APPROVED BY: _� tJ ie EMPLOYEE#: cC X <br /> ASSIGNED TO: C S r EMPLOYEE#: j C.{ DATE: D g <br /> Date Service Completed (if already completed): SERVICE CODE: !�(S P 1 E: 2&0 ? <br /> Fee Amount: j _ Amount Paidw Payment Date \ 2�f 6 g <br /> Payment Type I/ Invoice# Check# L S Received By: �s <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />