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SAN JOAQt&*UNTY ENVIRONMENTAL HEALTO\RTMENT <br /> SERVICE RT'Q FST <br /> Type of Business or Property FACILI Ty ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Mr. Dale Adema CHECK If BILLING ADDRESS <br /> FACILITY NAME Wildwood Ranch, LLC <br /> SITE ADDRESS 15445 E. Wildwood Road95215 <br /> Stockton <br /> Street Number Direction I Street Name city I Zia Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1700 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 Unassigr3ed <br /> PHONE#2 EXT. BOS DISTRICT LOCATIO OD <br /> CONTRACTOR / SERVICE REQ UESTOR <br /> REQUESTOR 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# V <br /> 902 Industrial Way (209 )369-4228 <br /> CITY Lodi STATE CA ZIP 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. �f;t�1y� <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all 81�(JZiQOIN' <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Neil O. Anderson &Assoc., Inc. DATE: . T'( <br /> COON <br /> PROPERTY/13L SINE.SS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTIIORIZED AGENT® Consultant SAN JUAQv MENTAt- <br /> IfAPPL1C'ANT is not the BILLING PARTY,proof of authorization to sign is required Title NEAtT� OFP tMENt <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: 5LU4 <br /> COMMENTS: Please review the attached Surface Subsurface Contamination Report. If you have any <br /> questions, please do not hesita a to call. <br /> 21 S %��zJ Abby <br /> 0. <br /> APPROVED BY: A� -�jJ G'L EMPLOYEE#: /, DATE: <br /> ASSIGNED TO: ! r EMPLOYEE#: ` DATE: J (l <br /> Date Service Completed (if already Completed): SERVICE CODE: P i E: <br /> Fee Amount: ' . , Amount Paid - �� Payment Date 3 yel >J <br /> Payment Type Invoice# Check# ,jq I I Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />