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SAN JOAQU? COUNTY ENVIRONMENTAL HEALTH T -PAR�TMIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> d OWNER/OPERATOR <br /> Mr. Armando Huerta CHECK If BILLING ADDRESS® <br /> FACILITY NAME Huerta Construction ----] <br /> SITE ADDRESS 11573 Norman Avenue Stockton 95215 <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 11923 Norman Avenue <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95215 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# �h( -D L4—7z Z <br /> (209) 467-0622 103-280-14 Unassigned <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 1 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Nancy Rosulek CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <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: 1, 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 hat the wor to be pe rmed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,. TATE and FED RAL laws. <br /> r � <br /> APPLICANT'S SIGNATURE: DATE: 0 1%5 I V'`S��/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is require Tit I e <br /> f <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. PAYMENT <br /> TYPEOFSERVICEQUESTED: S 1ion-RBpott - RECEIVED <br /> COMM J C (L &�Pt r-->, t L t cd y NOV 2 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> NOv I t V001 HEALTH DEPARTMENT <br /> ,meqI r � /�l EMPLOYEE#: 3 Z/ DATE: l� C <br /> A S GNED TO: }1 S/ C Y D t,_C—LS EMPLOYEE#: t; DATE; <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid b ,ou Payment Date \\ 2-16 S <br /> Payment Type Invoice# Check# c�� Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />