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SAN JOAQUIN NTY ENYIR(SNMEDfTALHEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY ID# SERVICE//REQUEST# <br /> ��N <br /> OWNER/OPERATOR Tom Gassner <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME More-Gas Property <br /> SITE ADDRESS 11230 E. Jahant Road Acampo 95220 <br /> Street Number Direction Street ma ciw I Zio Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 2919 Heritage Oak Way <br /> Street Number trees Name <br /> CITY Lodi STATE CA ZIP 95242 <br /> PHONE#1 Eir. APN# LAND USE APPLICATION# <br /> (209)423-6282 007-380-11 Unassigned <br /> PHONE#2 JS DISTP.. <br /> I ) I 1 11 CA <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ev' <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 we 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, TATE an EDERAL laws. <br /> APPLICANT'S SIGNATURE: Neil o.Anderson&Assoc.,Inc. DATE: September 28,2005 <br /> PROPERTY/BUSINESS OWNER❑ OP TOR/MANAGER ❑ OTHERAUTHORIZED AGENT® Consultant <br /> /JAPPLLCANT 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 t0 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: �.t.t.taA-E=� �u ssru .t-,;e C'-ee<JT" • Pa/zT PAYMENT <br /> COMMENTS: <br /> .b SEP 2 9 2005 <br /> I SANCOU <br /> ENVIRONMENTAL ENTAL <br /> HEALTH DEPARTMFI IT <br /> APPROVED 9Y: C) i Ur i A f� EMPLOYEE#: O3 Z,/ DATE: <br /> ASSIGNED TO: i N'4 EMPLOYEE#: 5-3/Ob DATE. �! 24 llL DS <br /> Date Service Completed (if already completed): SERVICECODE: 3 1,5 P 1 E: .ZCo-Q.3 <br /> Fee Amount: (o •rC0 Amount Paid / Payment Date ( �� <br /> Payment Type ✓ Invoice# Check# g Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />