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SAN JOAQUu. COUNTY ENVIRONMENTAL HEALTH iiEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 6 <br /> WNER/OPERATOR <br /> '::� lMosCHECK If BILLING ADDRESS❑ <br /> � <br /> FA LITY NAME ��sG �(���^ ;�� <br /> SITE A ESS F �o�L �� I's,�-4to <br /> Street Number Direction Street Name city. Zi Code <br /> HOME orG ADDRESS (if Different fro Site Address) <br /> W5 X <br /> Street Number Street Name <br /> CITY GS STATE vAZIP 1`>/ 12-I <br /> OC�_ lP <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> 1 ) 2Zt'1- Zoa 'Zj0 + Zi 1 OUB <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 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 Way (209 )369-4228 <br /> CITY STATE 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. <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: ATE: <br /> PROPERTY/BUSINESS OWNER❑ tiheILLING <br /> ATOR/MAN. ER [3OTHER AUTHORIZED AGENT❑ Cv <br /> If APPLICANT is not 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. <br /> TYPE OF SERVICE REQUESTED: �j S S r,�L S�( S!L i �-1 S I�C�� EIVED <br /> COMMENTS: P 70, .ir I Fri <br /> JUL 3 1 2008 <br /> 3160 SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL <br /> Du�1 HEALTH DEPARTMENT <br /> APPROVED BY: oc, 44 EMPLOYEE#: 03� ! DATE: -31 b t <br /> ASSIGNED TO: *T-A—t p-�v Lt L a-r EMPLOYEE#: �t DATE: I jt v k <br /> Date Service Completed (if already completed): SERVICE CODE: 5ZZ P E: a�O <br /> Fee Amount: 1c� Amount Paid I9 b Payment Date 3 I J 8 <br /> Payment Type ✓' Invoice# Check# S `l g Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />