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SAN JOAQ J COUNTY ENVIRONNrl 1TAL HEAL' DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# S(Z U 0,_5 OWNER I OPERATOR Frank Alegre CHECK if BILLING ADDRESS FACILITY NAME Alegre Property SITE ADDRESS 5184W. Highway 12 Lodi 95242 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 4988 W. Hi�hway 12 Street Number Stree Name CITY Lodi STATE CA ZIP 95242 PHONE#1 ExT. APN# LAND USE APPLICATION# ( 209) 368-7664 55-160-22, 23, 24, 25, 43, 4 Unassigned PHONE#2 ExT• BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR Abby Racco CHECK If BILLING ADDRESS BUSINESS NAME PHONE# Ext. Neil O. Anderson & Associates Inc. 209 367-3701 HOME or MAILING ADDRESS FAx# 902 Industrial Way (209 )369-4228 CITY Lodi STATE CA ZIP 95240 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes,Standards,STATE and FEDE)tAL lbws. APPLICANT'S SIGNATURE: DATE: r7 a U PROPERTY/BUSINESS OWNER R OPERATOR/AANAGER ❑ OTHER AUTHORIZED AGENT❑ If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: A- 17-;4,-T-E7 L--r-,A a r,v c - s—L.t o COMMENTS: Please review the attached Soil Suitability Study. The report review fee of$465 will be _ Nl attached by Frank Alegre. If you have any questions, please do not hesitate to call-,�b')�'E� APPROVED BY: L� t (>� EMPLOYEE#: �i 3 2-1DATE: -7 'J Et�f ASSIGNED TO: /_ [S EMPLOYEE#: LIC/ DATE: ::? ` EPRR Date Service Completed (if already completed): SERVICE CODE: S 2 PIE: 26 < Fee Amount: 4 b Amount Paid (o s Payment Date q �/ Payment Type Invoice# Check# [t)'9'3 Received By: EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02