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SAN JOAQ. BOUNTY ENVIRONMENTAL HEAL' ?PARTMENT <br /> SERVICE RhQUF5T <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1 <br /> OWNER/OPERATOR / <br /> Mr. Dale Adema CHECK If BILLING ADDRESSO <br /> FACILITY NAME Wildwood Ranch, LLC <br /> SITE ADDRESS 15445 E. Wildwood Road95215 <br /> Stockton <br /> Street Number Direction Street Name city I Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1 700 Standiford Avenue <br /> Street Number Street Name <br /> CITY Modesto STATE CA ZIP 95350 <br /> PHONE#'1 EXT. APN# LAND USE APPLICATION# <br /> (209)549-1830 203-140-01 ..thrassd t! <br /> PHONE#2 EXT. BOS DISTRICT LOCATIO OD <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco 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 Wa (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. �(U <br /> rAY�.r�D <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all IJJ k [71IV <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. 2zb5 <br /> APPLICANT'S SIGNATURE: Neil O.Anderson&Assoc., Inc. DATE: Ahs 2' 9 TY <br /> COON <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT® Consultant SANJOAONMENTA&- <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title EALTH DEPN <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property lHocated 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: ( 1 v <br /> COMMENTS: Please review the attached Surface Subsurface Contamination Report. If you have any <br /> questions, please do not hesita e t call. <br /> 5/Z5/0s S— yo211'" Abby <br /> �� <br /> APPROVED BY: ,/J EMPLOYEE#: &I iqDATE: zL <br /> ASSIGNED TO: v 65 EMPLOYEE#: DATE: (• <br /> —1 <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: , Amount Paid �� - Payment Date <br /> Payment Type Invoice# Check# 115q I Recelved By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />