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- � r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR Mr. and Mrs. Blomberg �/� CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 2289S Hollenbeck Road Stockton 95215 <br /> Street Number I Diction I Stnnt Name CAV Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) v� <br /> Street Number SVeet ame ^^-'^ <br /> CITY STATE ZIP 1 <br /> PHONE#1 ECT. APN# LAND USE APPLICATI N# <br /> ( 209) 466-3894 183-170-10 —p . <br /> PHONE#2 EM. B S DISTRICT -OCATIO CODE , <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Nancy R. Kramer CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# Ems' <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209 ) 69-4228 <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,Standards,STATE and FEDERAL laws. <br /> 1 <br /> APPLICANT'S SIGNATURE:--}.__jDATE: S v K <br /> L <br /> PROPERTY/BUSINESS OW NER iiyM 4PERATOR/M�NAGER ❑ OTHER AUTRORIZED AGENT❑ -.,y..--C <br /> IfAPPL/CANT is not the BLLLING 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 i5 available and at the Same time it is <br /> provided to me or my representative. p <br /> TYPEOF SERVICE REQUESTED: Soil Suitability Study EOC( 7 <br /> COMMENTS: 1 ^ <br /> 07 <br /> LAe <br /> JUL 3 1 21,1 <br /> a,,,,, • JV`` SAN UQAQUIIV c <br /> A- 6 Hf�HRo pA&M L <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE ODE: {/ (/ P E. <br /> Fee Amount: Amount Paid ` _ Payment Date 3� <br /> Payment Type �_..- Invoice# Check# z,Z-0 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />