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I <br /> l s r SAN JOAQUI- --,OUNTY ENVIRONMENTAL HEALTd�,EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5P'oQ SSc� S � <br /> OWNER 1 OPERATOR <br /> Joseph Eger CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> E er Property <br /> SITE ADDRESS 751 E Forest Lake Road =Acampo 95220 <br /> Street Number Direction Street Name I Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1077 E. Peltier Road <br /> Stn tet Number Street Name <br /> CITY <br /> STATE ZIP <br /> Acampo 95 95220 <br /> i <br /> PHONE#t EXT. APN# LAND USE APPLICATION# ` <br /> - (209) 482-4451 003-130-01 PAr - OQ (M,5) <br /> PHONE R EXT. BO$DISTRICT LOCA ODE <br /> i <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Tamara Woods <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# E"'' <br /> Neil O. Anderson &Associates, Inc. <br /> 209 367-3701 <br /> Hann_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 identified on this form. <br /> I also certify that I have prepared this ap c i nd t a th ork to be performed will be done in accordan e with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, A FED L s. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER El P OR/MANAGER OTHER AUTHORIZED AGENT® Consultant <br /> If APPLICANT is not theB LING 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: Surface Subsurface Contamination Report <br /> COMMENTS: R�DL J <br /> VIED <br /> SANjo.4Q 172009 <br /> y���RD AMe�o�N7Y <br /> ACCEPTED BY: C'> EMPLOYEE#: I DATE: <br /> ASSIGNED TO: EMPLOYEE#: 6 q L( DATE: g I ,o <br /> Date Service Completed (if already completed): SERVICE CODE: 3 PIE: <br /> Fee Amount: 0, � Amount Paid Payment Date id f <br /> Payment Type Invoice# Check#M-2�d1D¢�� .� eceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED I Ih712003 <br />