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�b <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#:A <br /> ERVICE REQUEST# <br /> E540S <br /> 04554 S <br /> OWNER i OPERATOR <br /> Mr. Tony Ghio CHECK If BILLING ADDRESS® <br /> FACILITY NAME Fairchild Ghio Limited Partnership <br /> SITE ADD 95205 <br /> 0 /?�245� mber Ir E.c / Florida Av t ran A e. Stockton City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from She Address) <br /> 29 Rosemarie Lane, Suite A <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95207 <br /> PHONE#1 I=. APN# LAND USE APPLICATION# <br /> 1209)601-2991 1 119-270-40 & -41 4 Jflassigned- /74 m o r <br /> PHONE#2 Etc BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Tina Cheney CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# 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 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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> JfAPPtrcANT is not the Ba/,mG PAR1r 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 is available and at the Same time it Is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: S 8 SUr�LFA+I F O <br /> COMMENTS: <br /> M f: G,5lrTto <br /> APPROVED BY:- �p� EMPLOYEE#: 7-3 (rO DATE: (/2,'/"Z' " <br /> ASSIGNED TO: AA ESC-C`7-0 EMPLOYEE#: DATE: 1120 /06 <br /> Date Service Completed (if already completed): SERVICE CODE: 315 P I E:2jov <br /> Fee Amount: 0 0 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />