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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Thomas Beard c/o Siegfried Engineering CHECK if BILLING ADDRESS® <br /> FACILITY NAME <br /> SITE ADDRESS 800 N. Shaw Road Stockton 95215 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 4045 Coronado <br /> Street Number Street Name <br /> CITY Stockton STAT --- `� 95204 <br /> PHONE#1 EXT. APN# LAN USE LICATION# <br /> ( 209)948-4803 143-270-38 / -�©Ice 2/ mS <br /> PHONE#2 EXT. BO S ISTRICT LOCATIJ ODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Tina Cheney 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, \n <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,STAT and FEDERAL OVS. <br /> APPLICANT'S SIGNATURE: DATE:, S-(S ' -7 /1C <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER 6 OTHER AUTHORIZED AGENT❑ ;w\ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: ot 5�2 GA I i G <br /> COMMENTS: J/A _ (� � ( MAY 1 7 20 J <br /> 1 ✓ O? <br /> 8AtV /OA <br /> H N R 1VM Coli <br /> T f DE AR ME ry <br /> NT <br /> APOVED BY' EMPLOYEE#: y�I, - DATE: <br /> ASSIGNED TO: )_�� EMPLOYEE#: DATE: <br /> DATE: y <br /> Date Service Completed (if already Completed): SERVICE CODE: '7 P I E: 4. (4 <br /> UC <br /> Fee Amount: 0 V U Amount PaidO Payment Date cJ \1 Q <br /> Payment Type Invoice# Check# Lk 3 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />