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SAN JOAQUVtwC.OUNTY ENVIRONMENTAL HEALTH w.LPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICEREQUEST# <br /> OWNER/OPERATOR Alan Hofmann, Bryan Hofmann, and San Neilsen CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Hofmann Property <br /> SITEADDRSU520 / 30972 1 East Lone Tree Road Oakdale 95361 <br /> S Straet Number n d r¢9S1 treat Name Ci ZI Code <br /> HOME Or MAILING ADDRESS (B Different from Site GO ftn Hofmann 9091 North Woodlawn Drive <br /> Street Number Street Name <br /> CITY Fresno exTE93 0 <br /> PHONE#1 Ex. APN# LAND USE APPLICATION# <br /> ( 559)269-2419 229-150-01 / 229-150-03 Unassigned <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> 1 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Crystal Spurr CHECK If BILLING ADDRESS® <br /> BUSINESS NAMEPHONE# 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 DEPARTMFNT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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. <br /> APPLICANT'S SIGNATURE: �)1 >�C,) � ..Neil o.Anderson&Associates,Inc. DATE: <br /> PROPERTY/BUSINESS OWNER 13 OPE TOR/MANAGERO OTHER AUTHORIZED AG ENT 9 Consultant <br /> If APPLICA,VT is not the BILLING PAR 7Y proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, t,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: Surface& Subsurface Contamination Report ` pP'*A sib <br /> COMMENTS: <br /> �eriet✓ �..t! �,pR �9 �ouNrr <br /> 40,61 �J°dG►V /d SA EN�tR�N PPR A ENT <br /> 1 TH DE <br /> APPROVED BY: (� (, I V'E( EMPLOYEE#: O22 'Z, DATE: t-/ <br /> ASSIGNED TO: �P��6-�.S EMPLOYEE#: '(�/�{ DATE: Ct(US <br /> Date Service Completed (if already completed): SERVICE CODE: 3 1 /E: ;LL-03 <br /> Fee Amount_ (Q 6.o Amount Paid Payment Date <br /> Invoice#ap, Check# Received By: <br /> Payment Type <br /> EHD 48-01-025 ' k �a,,,r,,,► SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />