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SAN JOAQU*COUNTY ENvtR NMEN7rAL HEALTH IIEPARTMENT r <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �l200 �/ �890 <br /> OWNER/OPERATOR <br /> Ms. Patricia Knowles CHECK If BILLING ADDRESS <br /> FACILITY NAME Knowles Property <br /> SITE ADDRESS 16411 S. Victory Rd. Oakdale 95361 <br /> Street Number Direction tree[Name Ci Zi Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) 13661 <br /> Valle Home Rd <br /> Street Number treet Name <br /> CITY CA 95631 Zip <br /> Oakdale <br /> 0 <br /> PHONE#1 En. APN# LAND USE APPLIcATIOOAL <br /> ( 209)847-2292 229-220- 30 __ Unassi nneTrd J L <br /> PHONE#2 EaT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Nancy Rosulek CHECK If BILDNG ADDRESS® <br /> BUSINESS NAME PHONE# Ezr. <br /> Neil O. Anderson &Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FA%# <br /> 902 Industrial Way (209 )369-4228 <br /> CITY Lodi $TATE 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,Standards, TATE and FEDER�i�laws. <br /> APPLICANT'S SIGNATURE: �— —DATE• Z o <br /> PROPERTY/BUSINESS OWNER OP BATOR i MANAG R 1377IER AUTHORIZED AGENT❑ <br /> IfAPPLtCAAtT is not the BlLL/NG PARTY proof of authorization to sign is required Titre <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. P V E NJ- <br /> TYPE OF SERVICE REQUESTED: SOII SuitabilityStudy IVED <br /> COMMENTS: JUN 0 5 2006 <br /> /ter ITI'ly/�/�O� SANJOAQUIN NOTA <br /> b / HEALTH DEPARTMENT <br /> APPROVED BY: / EMPLOYEE#: Y DATE: <br /> ASSIGNED TO: O Q EMPLOYEE#: tf6It 1 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S� P I E: Z 6 > <br /> Fee Amount: Amount Paid �86 �- Payment Date 6 s b <br /> Payment Type Invoice# Check# tj p Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 8-5-02 <br />