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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT r SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# L 1'--5 a-0 �' OWNER/OPERATOR S.T.A.N.D. Affordable Housing CHECK If BILLING ADDRESS® FACILITY NAME SREADDRES52927 & 2978 ,S Vista Avenue Stockton 95206 Street Number Direction treat Name Ci Zi Catle HOME or MAILING ADDRESS (If Different from Site Address)PO BOX 30231 Street Number street Name CITU Stockton STATE CA 913 PHONE#1 APN Is LA USE APPLICATION# ( 209-937-7625 175-040-18, -19 N- 0 5 004 3(, 5 u� PHONE#2 BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR Tammy Woods CHECK If BILLING ADDRESS BUSINESS NAME PHONE# Ev" 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 ENVHtONNfENTAL HEALTH DEPARTnEENT 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 ATE and F DERAL 1 APPLICANT'S SIGNATURE: O DATE: atz -7-7— 37 PROPERTY/BUsINEss OWNER IN OPERATOR/MANA t O OTHER AUTHORIZED AGENT O IJAPPLICANT is not the BILLING PAR TP 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: S��f%�E Sr�t/Li&tC diFC£ CO n1%/4✓K i.J�Q-Tz ti nJ /LT COMMENTS: 6401 r.n) SSG- RECEIVED /6130/66' ,Qi¢cu.J Rte'—w'^ /o/3I/o7 /¢dd4oa� H 1 � /e.�� C� ,�Lti�iQ y��r.=. +�1 cou gfy SAN^Ja�PONMENT�- APPROVED BY: O L-,V ec (?-4 EMPLOYEE#:. 6 3 ( - ASSIGNED TO: 00�r-- -T-(PeJ EMPLOYEEM -7'�`� DATE: _3 If 0-7 Date Service Completed (if already completed): SERVICE CODE: 3(,$' PIE: 2(0.03 Fee Amount: �j O . Amount Paid , l V , OU Payment Date 31q U l Payment Type El-� Invoice# Check# 5 Zy Received By: \vim EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02