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SAN JOAQUI-WCOUNTY ENVIIiowvI ),Li ,ALTH 14PARTMENT SERVICE REQ,JIS?` Type of Business or Property FACILITY ID# SERVICE REQUEST# 5�ov-36-7 -7fI OWNER/OPERATOR Jim Hoagland CHECK If BILLING ADDRESS FACILITY NAME Roland Construction SITE ADDRESS 3269 E. Tomahawk Drive Stockton o Street Number Direction Street Name CityZi Code HOME or MAILING ADDRESS (If Different from Site Address) PO Box 8670 Street Number Street Name CITY Stockton STATE CA zip 95208 PHONE#1 EXT' APN# LAND USE APPLICATION# (209 ) L -(o2.�2(09 092-210-28 PA-03-502 PHONE#2 EXT. CONTRACTOR /SERVICE REQUESTOR REQUESTOR David Welch CHECK if BILLING ADDRESS BUSINESS NAME PHONE# EXT, Neil O. Anderson & Associates Inc. 209 367-3701 HOME or MAILING ADDRESS FAX# 22 Houston Lane 209 869-4228 CITY Lodi STATE CA ZIP 95240 BILLING ACKNOWLEDGEMENT: 1, 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 tha e e performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,St ards, S F 1 ws. APPLICANT'S SIGNAT DATE: L 2 d PROPERTY/BUSINESS OWNER OP RA R/MANAGER ❑ OTHER AuTHoRizED AGENT❑ If APPLICANT is not the B NG ARTY proof of authorisation to sign is required Title AUTHORIZATION TO L INF MATION: 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: /U r L-CU A-0 I A!&- S-7-U U Y COMMENTS: Please review the attached SS/NLS. A report review fee of$465 will be submitted by the owner. If you have any que ti ns, please do not hesitate to call. Dave PAYMENT Y3o y . 3i��y 3//z/oNRF�C � D ,moi fjchck) �avta�,,�d•"Y /6-oe""J Wg 9 2004 iPPROVED BY: C)L EMPLOYEE#: 2 -Z ASSIGNED TO: /Jp0 b�S T EMPLOYEE#: (�l�� H iT'DEf� A�E�laT Date Service Completed (if already completed): SERVICE CODE: 5 2� PIE: 2 .C 2 t=ee Amount: GS Amount Paid Payment Date G p ayment Tyke Invoice it Check## b Received By:kIC E H D 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02