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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � <br /> t1J <br /> OWNER/OPERATOR <br /> Marco Pires/Cary Fooshee CHECK If BILLING ADDRESS <br /> FACILITY NAME Pires/Fooshee Property <br /> SITE ADDRESS/I 5(�(� Thornton Road Thornton 95686 <br /> O� Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Coronado Ave. <br /> C/o Siegfried Engineering, Inc. 4treet 04 <br /> umber Street Name <br /> CITY Stockton STATE CA ZIP 95204 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# — <br /> (209)943-2021 001-150-55; �assigped J <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco 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 ENVIRONMFNTAI. HFALTH 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 al! SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERA aws. / <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTVIBUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTIIERAUTHORIZEDAGENT <br /> � floq��/ ��//✓C�0/ <br /> /f APPL/CANT is not the BILLING PARTY,proof ojauthorization 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. MY ltzfff <br /> TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report BECEIVED <br /> COMMENTS: <br /> OCT - 4 2006 <br /> �✓O? ii�, SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: � __� EMPLOYEE#: 7 DATE:379 <br /> ASSIGNED TO: , tL` EMPLOYEE#: _ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid � D Payment Date 10 O <br /> Payment Type ✓ Invoice# Check# b5 3 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />