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SAN JOAQUh rCOUNTY ENVIRONMENTAL HEALTH -iPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER/OPERATOR Mr. Keith Watts CHECK if BILLING AODRESSE] FACILITY NAME Watts Property SITE ADDRESS 17667 E. Liberty Road Galt 95632 Street Number Direcdon Street Name C oda HOME Or MAILING ADDRESS (If Different from Site Address) 8100 East Orchard Road Street Number St,,mt Name CITY Acampo STAZA ZI65220 PHONE#1 En. APN# LAND USE APPLICATION# ( ) 009-090-08 & 009-080-02 Unassigned cC PHONE#2 Ezr_ BOS DISTRICT LOCATION CODE ( 1 CONTRACTOR/ SERVICE REQUESTOR REQUESTOR David Welch CHECK N BILLING ADDRESS® BUSINESS NAME PHONE# En. Neil O. Anderson & Associates Inc. 209 367-3701 HOME or MAILING ADDRESS FAX# 902 Industrial Way (209 )369-4228 CITY Lodi STATE CA ZIP 95240 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with ail SAN JOAQUIN COUNTY Ordinance Codes,Slanda , ST E and FEDERAL laws. PAYMENT APPLICANT'S SIGNATURE: DATE: G I—/�-OCr RECEIVED PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 10 Consultant ZpQ4 IfAPPLICANT is not the BILLING PARTY Proof Of authorization to sign is required TitleNUV AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the proper•tVfcDithEOUNTY above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/siteEK'so&Abr&N MEM Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SS soon as it is available and at the HIBMA hliq provided to me or my representative. TYPE OF SERVICE REQUESTED: u u��A[ _S U.%,S CT>4L CC V / � .�'✓ I — QC d / COMMENTS: Per the request of the client, we have submitted the SSCR along with the expedited review fee of$279 ($18 . If yo l have any questions, please do not h"esitate�to call. APPROVEDBY: OLI V.El" EMPLOYEE#: 032-( DATE: ASSIGNED TO: M e,�, ti A EMPLOYEE#: S3(oc-, DATE: Date Service Completed (if already comp) d •C, Ci0 SERVICE CODES r.5- PIE:�Cr.03 Fee Amount: &6_ j 5 Amount Paid �vl C7, p � i Payment Date t 4 Payment Type Invoice# Check# (�8'Sj Received By: /� EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02