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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> .512oo¢�y, <br /> OWNER OPERATOR <br /> Madalena Moules CHECK If BILLING ADDRESS® <br /> FACILITY NAME Moules Property <br /> SITE ADDRESS .to��11 f.1 Jack Tone Road 95240 <br /> 13737 & st4 iNumber Dtve Non 8e1 Lodi <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 12951 E. HarLane <br /> Street Numbar StreetetName <br /> CITY Lodi STATE CA ZIP 95240 <br /> PHONE#1 En. APN# LAND USE APPLICATION# IIA, (-- Q <br /> ) -s s) <br /> Q0911333 � +ga �f i—ICITo 063-250-27 asseV VLL/ <br /> PHONE#Y Ex . BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Tina Cheney CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# E1tr• <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 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. n Q �7 <br /> APPLICANT'S SIGNATU�r�Rrr(rE: _ _ _ _ _ �- � YDATE: / — d �—D <br /> PROPERTY/BUSINESS OWNERCL OPERATOR I MANAGER 13 OTHER AUTHORIZED AGENT 13 <br /> IjAPPLICANT/r is not the BILLING PAR proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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:�C�'LL W-)CAc �v_b�i.l oma'' c-E C(D•-- r ,T+-t C nit4-r7,9,J P <br /> COMMENTS: S t l a` <br /> 18SAIN-7 « 3 M t- MAR 2 7 2006 <br /> 'AN JOAQui, <br /> (GoirnJ� <br /> HEALTH IRONME OU <br /> 1) AL <br /> APPROVED BY: VLt%)Et 4-A- EMPLOYEE#: 07)'2--f DATE: 3 O <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> J t 0& <br /> Date Service Completed (if already completed): SERVICE CODE: 3 is PIE: <br /> Fee Amount: - / g-� ,U\D Amount Paid \ C b , Payment Date -312,116'6 <br /> Payment Type �� Invoice# Check# Received By: \vim <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-6-02 <br />