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SAN JOAQU -OUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SO©0 -�2/g-7-- <br /> OWNER i OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Rodgers Parcel <br /> SITE ADDRESS 6881 S Roberts Road Stockton 95206 <br /> S[reet Number Direction Street Name City i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 566Whitney Court <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Tracy CA 95377 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> 1250-110-11 PA- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Dave Welch <br /> BUSINESS NAME PHONE# EXT. <br /> Neal 0. Anderson and Assoomates, Inc- ( 209)367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 209 369-4228 ( 209)369-4228 <br /> CITY Lodi STATE CA ZIP 4 <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 A and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El tU ant <br /> If APPL/CANT 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 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: Expedited SOLI Suitability Study Review <br /> COMMENTS: <br /> 3 <br /> 4t$ <br /> APPROVED BY: EMPLOYEE#: ` DATE: 5 /„ <br /> ASSIGNED TO: EMPLOYEE#: DATE: w <br /> Date Service Completed (if already completed): SERVCODE: P/E: <br /> ICE <br /> Fee Amount: e�c� Amount Paid 43 ZJ Payment Date 0 <br /> Payment Type Invoice# Check# G !/ �7 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />