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�) o <br /> ' ►vvo <br /> ti <br /> SAN JOAQL COUNTY ENVIRONMENTAL HEALTh EPARTM N <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Wildwood Ranch LLC <br /> SITE ADDRESS 10151 S Murphy Road Stockton <br /> Street Number Direction Street Name cityCod <br /> HOME or MAILING ADDRESS (If Different from Site Address) P.O. Box 97 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Salida CA 95368 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( ) 203-150-01 PA-04-34-e-(SA) �v(C <br /> PHONE#2 ExT• BOS DISTRICT i LOCATION UE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS X <br /> BUSINESS NAME PHONE# ExT. <br /> Neil 0- Anderson and Assodates, Inc- (209)367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 2 Industrial Way (20 )369-4228 <br /> CITY Loch STATE CA zip 95240 _J <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: o A— DATE: 10 �— <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAG R ❑ OTHER AUTHORIZED AGENT® consultant <br /> if 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. \ 1 <br /> TYPE OF SERVICE REQUESTED: Gj o 1 S b/�l �i d— t�Ys �o �11 eVJ <br /> COMMENTS: ///��OS /����0� //�!�l� �` <br /> OCT 13 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPAR ENT <br /> APPROVED BY: EMPLOYEE#: DATE: a <br /> ASSIGNED TO: L/kp_ <br /> S Cj���/Y� ^YEE#: <br /> Date Service Completed (if alreadyCcommpletedf: � " SERVICE CODE: J/'7G P 1 E:2 <br /> Fee Amount: Amount Paid L.,6 S,OD Payment Date `p v's►OS <br /> Payment Type ✓ Invoice 4 Check# g q cj Received By: N G <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />