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SAN JOAQUV --OUN TY ENVIRONMENTAL HEALTH _ -11ARTMOT <br /> 4W-01 SERVJCE 77-EQUEST *are <br /> T=&Buosipoess or Property FACILITY ID# SERVICE REQUE5TOWNER I ERATOR Mr. Craig Watts CHECK if BILLING ADDRESS® <br /> FACILITY NAME Watts Parcel <br /> SITE ADDRESS 30003 N. Vail Road Thornton 95686 <br /> Street Number Direction Street';ame Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) P.O. Box 358 <br /> Street Number Street Name <br /> CITY Walnut Grove STATE CA zip95690 ) <br /> PHONE#t <br /> EXTAPN# LAND USE APPLICATION# -0 Wo ,Itn <br /> (209)794-2871 001-090-02 <br /> PHONE#Z EXT. BOS DISTRICT r J LOCATION CODF�� �J`• <br /> ( } t�tC C' 1 <br /> CONTRACTOR/ SERVICE REQUESTOR c� <br /> REQUESTOR Abby Racco CHECK if BILLING ADDRESS El <br /> BuSINEss NAME PHONE# Ev. <br /> Neil O. Anderson & Associates. Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FAX# C <br /> 902 Industrial Way (209 )369-4228 <br /> CITY Lodi STATE CA ZIP 95240 `Y <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 d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STAT d FEDERAL <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUS[NESS OWNER® 0PERATO i IANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BIL Ll ' 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: <br /> COMMENTS: please review the attached Surface Subsurface Contamination Report. Tftno <br /> Wale fee <br /> of $186 will be attached by Mr. Watts. If you have any questions, please We <br /> to call. %/��c�5 FEB 4 2oo5 <br /> Abby SANJ <br /> oActur <br /> I yf-, ENV N COUNTY <br /> APPROVED 8Y: �1� EMPLOYEE : U TD <br /> ASSIGNED TO: EMPLOYEE#: r TE: <br /> Date Service Completed (if already completed): SERVICE CODE: �3'� P�/Ei <br /> Fee Amount: t Amount Paid l -- Payment Date <br /> Payment Type Invoice# II Check# Received By: <br /> EHD 48-01-025 'I SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br /> ltl� <br /> `l1 <br />