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-tet <br /> SAN'JOAQLTIti fOI1NTY ENVIRONMENTAL HEALTH T 'a PARTMENT V <br /> SERVICE REQUEST. <br /> r: <br /> Type of Business or Pro erty: :. FACILITY ID# 7T _ SERVICE REQUEST# <br /> OWNER I OPERATOR Mr. Craig~Watts CHECK if BILLING ADDRESS® <br /> FACILITY NAME Watts Parcel <br /> SITE ADDRESS 30003' N. Vail Road Thornton 95686 <br /> Street Number I Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) P.O. BOXa 358 <br /> Street Number Street Name <br /> CITY Walnut Grove STATE CA ZIP 95690 <br /> PHONE#f ExT• APN# LAND USE APPLICATION# <br /> (209)794-2871 001-090-02 <br /> _ PHONE#2 Exr. - BOS DISTRICT��� J „' LOCATION COCySz �J`� <br /> �/jl C•If <br /> CONTRACTOR 1 SERVICE REQUESTOR n <br /> REQUESTOR Aby Racco <br /> 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: 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,hourlycharges 'associated with this project 1� <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 applicationond that the work to be performed will be done.in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT 'rd FEDERAL <br /> APPLICANT'S SIGNATURE: DATE: cX/ <br /> PROPERTY/BUSINESS OWNER® OPERATO ANAGER ❑ OTHER AuT- HORIZED AGENT❑ <br /> IfAPPLIC4NT is not the BILLI PARTY proof of authorization to sign is required Tide <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 /> l provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ' <br /> COMMENTS: please review the attached Surface Subsurface Contamination Report. TIS f w.fee <br /> I. of$186 will be attached by Mr. Watts. If you have any questions, please'do n . � e <br /> to call. FEB 14 <br /> nQ5 <br /> I <br /> ;Abby s,N OAQUN coy <br /> NTY <br /> APPROVED BYVV <br /> .: [J Q � � ': EMPLOYEE <br /> rt ASSIGNED TO � >r m,: EMPLOYE. #: DATE. <br /> l <br /> 3 C <br /> Date Service Completed (if already completed): s` mm SERVICE C06E: P!E; <br /> o <br /> r Fee Amount r �-- Amount Paid Payment Date -- <br /> Payment Type_ Invoice# Check# Received By: <br /> y <br /> I <br />} t 48-01-025 <br /> SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br /> CP � , <br />