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SAN JOMQUInT'ICOUNTY ENVIRONMENTAL HEA'!?°H APARTMENT <br /> SERVICE REQUEST <br /> PArmondo <br /> ss or Property FACILITY ID# SERVICE REQUEST# <br /> _Sly C (_� �� C% C I <br /> RATOR <br /> Huerta c/o Fred C. Ingalls, PLS CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Huerta Property <br /> 1255 &11515 E Norman Avenue Stockton 95215 <br /> SITEADDRESS1 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4045 Coronado Avenue <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95204 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) 103-280-12 & -13 Prepared in advance of PA No. <br /> PHONE#2 Ex T. BOS DISTRICT ---][LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Neii 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 Iden ified on this form. <br /> I also certify that I have prepared this application and at the ork to b performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar STATE and FE RAL la s. <br /> APPLICANT'S SIGNATURE: DATE: C <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 to the SAN JOAQUIN COUNTY ENVIRONMENT A EALTH DEPARTMENT as soon as it is available and at the sante time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 5 C 2 S 5 <br /> COMMENTS: <br /> Or,-47 <br /> �cF�Fti� <br /> �o <br /> Q� B<00Q <br /> ACCEPTED BY: �, �� EMPLOYEE#: <br /> ASSIGNED TO: EMPLOYEE#: 'DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: d 3 <br /> Fee Amount: �� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />