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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ..5io-oC ; � U zci <br /> OWNER/OPERATOR <br /> Louise M. Woehl for the Thelma E. Hieb Revocable Trust CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS 10940 E. Harnev Lane Lodi 95240 <br /> Street Number Direction Street Name Cit 2i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4325 Driftwood Place <br /> Street Number Street Name <br /> CITY Discovery Bay STATE CA ZIP 94505 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (925)437-9040 ��J. �� -0 /'� -- 0111) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Nancy Kramer CHECK If BILLING ADDRESSE <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: 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 JOAQUTN <br /> COUNTY Ordinance Codes,Standards,STATE apd FEDERAL laws. <br /> APPLICANT'S SIGNATURE•;,- G? i Uy ^J DATE: December 26, 2007 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El Project Manager <br /> IfAPPL/CANT 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-a ISau 4flue it is <br /> provided to me or my representative. ID) <br /> TYPE OF SERVICE REQUESTED: Soil Suitability Study PAYMENT <br /> COMMENTS: "0 D� L', 2 7 LSU( OEC <br /> T . <br /> � �CClTc �r z SAN JOAQUIN COUN4NVIRrINMENT HEALT H <br /> ENVIRONMENTAL PERMIT/SERVICES <br /> HEALTH DEPARTMENT <br /> APPROVED BY: EMPLOYEE#: �?d-10 DATE: <br /> ASSIGNED TO: EMPLOYEE#: -7 /DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E O' <br /> Fee Amount: ( b VJ Amount Paid C b 0 0 Payment Date U Z 0 <br /> Payment Type Invoice# heck# � 1 S Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />