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i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICrRM*UEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Ed Craig CHECK If BILLING ADDRESS® <br /> FACILITY NAME Ed Craig Property <br /> SITE ADDRESS 20913 East State Highway 12 Clements 95227 <br /> Street Number Direction I CIN Zip C.de <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EaT APN# LAND USE APPLICATION# <br /> (209 ) 334-9142 112 0231030-36,-7,-6 & 023-110-01, 11, -12, -22, -23, -24 <br /> PHONE#Z E+T BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR James Robinson 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 appli f n and t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST and FE laws. <br /> APPLICANT'S SIGNATURE: DATE: /2J OS <br /> PROPERTY/BUSINESS OWNERC4 ATOR/MANAGER J <br /> yy B ❑ OTHER AUTHORIZED AGENT <br /> IfAPPL/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: S l&Ie-FACE U_✓SFA-E 5: OA) I e�yT <br /> COMMENTS: Please review the attached rface & Subsurface Contamination Report. The re�g("O vE <br /> review fee of$186 is attached by Ed Craig. If you have any questions, EGE <br /> pl ase do not,hesitate to call. James <br /> PQSNC <br /> APPROVED BY: EMPLOYEE#: ©�Z DATE: EPP SM�� <br /> ASSIGNED TO: w_.1 ��J�tC^/ EMPLOYEE#: �'3�, DATE: a <br /> Date Service Completed`(if already completed): SERVICE CODE: – P 1 E:a L.03 <br /> Fee Amount: 707— <br /> Amount Paid 6!I c�'1 D-D Payment Date '✓ql vs <br /> Payment Type Invoice# Check# Receive By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />