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SAN JOAQU . —'OUNTY ENVIRONMENTAL HEALti H_ _°ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> '52oo -415 Z.- <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Mr- Stan Robertson <br /> FACILITY NAME <br /> 1999 West Linne Road Property <br /> SITE ADDRESS 1999 W Linne Road Tracy 95304 <br /> Street Number Direction Street Name citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 27337 South Banta Road <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Tracv CA 95376 <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> ( ) 239-210-06 & 239-210-07 PA-04-090 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS El <br /> Dave Welch <br /> BUSINESS NAME PHONE# EXT. <br /> Neil 0- Anderson and Assocffiates, Inc. (209)367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (20 9) -422 <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. <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,Stand TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATUR DATE: 1 �1 O J <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Consultant <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: So i L S u r T—ft i3t C.tT y STLtp ��1 C <br /> COMMENTS: �• <br /> Please review the following Soil Suitability Study. We have will attached tkivlce review <br /> fee of$186. If you have any questions please call. 9 � I1 2005 <br /> Dave /9/05- &/lU/� // MAR OO <br /> CAl• F E�c c> I.f �c�77� �C.{I.XA� t J�LFONM��MENT <br /> APPROVED BY: EMPLOYEE#: 03 2 / L� 3/t I os <br /> ASSIGNED TO: ti�SC�T� EMPLOYEE#: 59wil DATE: 3 /(1 /QS <br /> Date Service Completed (if already completed): SERVICE CODE: ��� P/E: <br /> Fee Amount: `Na DO Amount Paid lj Payment Date �,t? <br /> Payment Type Invoice# Check#1710 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />