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SAN JOAQUIN COUNTY ENVIRONMENTAL HEIV LTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# pSERMCE REQUEST# <br /> S R D G L-( Zlo <br /> OWNER/OPERATOR <br /> Mr. George Garcia CHECK IT BILLING ADDRESS <br /> FACILITY NAM Garcia Property <br /> SITE AD ss5153 & 5133E. Main Street Stockton 95215 <br /> set Number re n Street Name CRVCode <br /> HOME Or MAIL DRESS (If Different from Site Address) P.O. Box 55331 <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP95205 <br /> PHONE#1 ECT. APN# LAND USE APPLICATION# <br /> (209)462-7600 159-100-004 &159-100-006 Unassigned <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# En. <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: 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 1 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 <br /> FEDpE.RAL laws. f <br /> APPLICANT'S SIGNATURE: Z� -Ick IIIc_� DATE: <br /> PROPERTY/BUSINESS OWNER O OPERATOR/MANAGER W OTHER AUTHORIZED AGENT 13 <br /> /f APPL/CANT is not the BLLL/NG 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. <br /> TYPE OF SERVICE REQUESTED: yL <br /> COMMENTS: please review the attached Surface Subsurface Contamination Rep review fee <br /> of$186 will be alta ed by Mr. Garcia. If you have any questions, Is o no esitate <br /> to call. Abby �0 JUN 13 2005 <br /> JQAGLIN COUNTY <br /> APPROVED BY: EMPLOYEE#: H .pL=YA 0 <br /> ASSIGNED TO: ae 1EMPLOYEE#: DATE: <br /> Date Service Completed (H already completed): SERVICE CODE: '7J E P I E: <br /> Fee Amount: Amount Paid �' g Payment Date <br /> Payment Type Invoice# Check# — Received By <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />