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t <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 10# SERVICE REQUEST# <br /> S�0 0 5 <br /> OMER i OPERATOR <br /> Jose&Graciela We CHECK if$ILLING ADDRESS <br /> FAciurr NAME <br /> p SITE ADDRESS 407S Del Mar Stockton <br /> E S Nu her e <br /> f� HOME or MAILING ADDRESS (If Dwereat from Site Address) 1255 W.Armstrong <br /> Number -Stmd Name <br /> i CITY Lodi STATE CA ZIP 95242 <br /> PHONE#f EXT. APN a LAND UsE APPLICATION# , <br /> 1209 1369•-6682 159-055-10 jw-eo-dol /mss <br /> PHONE#Z EXT B05 DISTRlGTLOCAIq�ODE <br /> ( 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Tina Cheney CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Nell 0. Anderson &Associates Inc. 209 367-3709 <br /> HOME or MAIuNG ADDRESS FAX# <br /> 902 Industrial Way (209)369-4228 <br /> CITY Lodi STATE CA 71P 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 /> 1 also certify that I have prepared this application and that the work to be performed wiI1 be done in accordance with all SAN JOAQUIN <br /> CouNTY Ordinance Codes,Standards,STATE and F ERAL Iaws. LO APPLICANT'S SIGNATURE: DATE: AP <br /> a <br /> PROPERTY i BUSINESS OWNERIA OPERATOR/MANAGER ❑ OTmit AuTHoRtm AGENT❑ <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 /> 1 information to the SAN JoAQUIN COUNI"Y 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: S' ¢.�,E s u✓1a S u P21=,q t_E C Q�l 4 t�[ c n� �0.1 <br /> COMMENTS: ! f2�fle f Z91 d V RECE!VED <br /> JUN 0 2008 <br /> SAN JOAQUIN cOUNN <br /> ENX,RONMENTq <br /> APPROVED BY: d C_ tJ i 4-A- EMPLOYEE#: 0 3Z� DATE: r <br /> ASSICTN£D TO: � ��✓I I� EMPLOYEE#: -Z 73'71. DATE: � <br /> Date Service Completed (if already completed): SERVICE CODE: 3 1 5 P/E: <br /> Fee Amount: c� Amount Paid \11 Payment Date b I ` <br /> Payment Type �� Invoice# Check# Received By: V2r-- <br /> EHD 4MI-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />