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ri SAN JOAQUTN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Bus! FACILITY ID# SERVICE REQUEST# <br /> ( (' t�i2teS <br /> OWMER I OPEWATOR Mran rS. Blomberg CHECK II BILLING ADDRESS® <br /> I <br /> FACILITY NAME <br /> SITEADDRESS 2289S Hollenbeck Road Stockton 95215 <br /> Street Number Direction I Street Name Ci Zi Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#i En' APN# LAND USE APPLICATION# <br /> ( 209) 466-3894 183-170-10 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> James Robinson CHECK if BILLING ADDRESS <br /> BUSINESS NAMEONE# ExT' <br /> Neil O. Anderson & Associates PH <br /> 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 ENVIRONMEN'T'AL 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,Stand70PTERATOR/AMIANAGER13 <br /> ATE and EDERAL laws. /) <br /> APPLICANT'S SIGNATURE: / DATE: <br /> PROPERTY/BUSINESS OWNERN OTHER AUTHORIZED AGENT <br /> IrAPPL/CANT is not the BILLING PARTY proof of authorization to sign is required Titte <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 HFALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. C uQ-F'Ac.C eta.c'�iu P,F+4c--E <br /> TIDE OF D: n ��/ <br /> CoMMEN L I }/O( etc✓taw _ // \0 L/S ASO <br /> 6 LUUU <br /> JAN 0 6 2006 <br /> SAN couto <br /> NONMENTAL <br /> ENVIRONMENT HEALTH <br /> HEALTH6EPAFITMEW PERP;"IT t-R ICES <br /> APPROVED BY: O L(U IF-t" EMPLOYEE#: 03-2-( DATE: / /1 <br /> ASSIGNEDTO: i0 v-Lo-C EMPLOYEE#: t. c"(� DATE: <br /> Date Service Completed (N already completed): SERVICE CODE: 3 (S"' 11 1 E:��, <br /> Fee Amount:' ell ALL) I <br /> Amount Paid I�(r,.� Payment Date / (' EI <br /> Payment Type C,"CZt,_ Invoice# Check# 151 3-ct-7 Received By: �j <br /> NEHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-502 <br />