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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH llEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �;9*v5a $ <br /> OWNER/OPERATOR <br /> James Rose Family Tract Properties LP CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS 997 8 & 99 5 W. Linne Road Tracy �( <br /> et Number Aelrection Street Name citvZi Code <br /> HOME,Or MAILING ADDRESS (If Different from Sit Address) 1885 The Alameda 4110 <br /> Street Number Street Name <br /> CITY � fan Jose STATE CA ZIP 95126 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> l 408► 246-6203 239-200-30 & -31 PA--0 9,40 6) 7l (t,4 J-5 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION�ODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Tamm Woods for Tina Cheney y 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 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,Standar TAT and FEDE L laws. �) <br /> APPLICANT'S SIGNATURE: DATE: 1 rI /1 " 7 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGEN7EI:� <br /> if APPLICANT 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. <br /> TYPE OF SERVICE REQUESTED: Y--fn S ce— C Y l vi +i 0 Y <br /> COMMENTS: ® t A� �d�� <br /> NOV 1 9 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: EMPLOYEE#: 38� DATE: <br /> ASSIGNED TO: D v EMPLOYEE#: O�6I �W4 <br /> DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I P 1 E:-,7L6 <br /> Fee Amount: 1 ° Amount Paid �0M I Payment Date �� `0l b ? <br /> Payment Type ✓ Invoice# Check# 2 bbl Received By: �'� <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />