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mohmal Poo( <br /> SAN JOAQU NTY ENVIRONMENTALHEALTH ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# 7VICE REQUEST#Sfgg33� <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Mr- Ga[y McAndrews <br /> FACILITY NAME <br /> Wildwood Ranch LLC <br /> SITE ADDRESS 10151 S Murphy Road 7Stockton Fy <br /> j <br /> Street Number Direction Street Name Cit Zi Code <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 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( ► 203-150-01 PA-04-346 (SA) <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 1 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Neel 0- Anderson and Assocqates, Inc- ( 209)367-3701I <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209)369-4228 <br /> CITY 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. <br /> 1 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. ff <br /> APPLICANT'S SIGNATURE: -S \e, DATE: k0 — l o <br /> PROPERTY/BUSINESS OWNER 11 PERATOR/MAN ERLr— 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: Surface Sub Surface Contamination Report <br /> COMMENTS: /11 I OCT 13 2005 <br /> I&vl m ✓/�,0 r'w"YI <br /> SAN JOAQUIN COUNTY <br /> /y!• C'SCd�d ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: I�LI L t£/KA EMPLOYEE#: ,�2) DATE: (0 /3 (s' <br /> ASSIGNED TO: E C V7T-i3 EMPLOYEE#: Li DATE: L) X31 <br /> Date Service Completed (if already Completed): SERVICE CODE:<3/S. P i E: a�, <br /> Fee Amount: Amount Paid \ b O Payment Date ck Z 3 S <br /> Payment Type Invoice# Check# rl Received By: N L <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />