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SAN JOAQUIN l OUNTY ErggRON j1ENTAL HEALTH L PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR Robert Edelman CHECK If BILLING ADDRESS <br /> FACRnY NAME Whiskey Slough Marina <br /> SITE ADDRESS 3401 Whiskey Slough Road Stockton <br /> Street Numlrer c' Zi de <br /> HOME or MAILING ADDRESS (If Different from Site Address) 18 Crow Landing Court <br /> Streit Number Street Name <br /> CITY San Ramon STATE CA ZIP 94583 <br /> PHONE#t APN# LAND USE APPLICATION# <br /> ( ) 131-080-13 PA-06-320 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> 1 1 3 se <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Nancy R. Kramer CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# Ems' <br /> Neil O. Anderson &Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FA%# <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 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 all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards/,�STATE and FEDERA laws. <br /> APPLICANT'S SIGNATURE: !Llf.� 1 DATE: / 0 7 - C� 7 <br /> LLL PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <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 /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Soil Suitability/ Nitrate Loading Study/ Engineered Septic EN7 <br /> COMMENTS: 1Ir2,I0)I /'W-yt ,Fokf 7o AAipY 191S)160- 0797 <br /> ebwePrur E r6a E / II„(,r1AN 1 1 2007 <br /> nl•F pRoPOs+a. 1.�FT sPA!/oA/ j[Aaf <br /> *iI[AW. f/ SAN JOAQUIN COUNTY <br /> HEALTH DEPAENTAL M NT <br /> APPROVED BY: ('�L( l.) I i�-7t EMPLOYEE#: 3 L 1 DATE: f /( 6 7 <br /> ASSIGNED TO: ESC OT-'D EMPLOYEE#:16-ZF* DATE: (('(07 <br /> Date Service Completed (N already completed): SERVICE CODE: !�-2 5 P 1 E: 2(0- O Z <br /> Fee Amount: L17 Amount Paid !� 5 r 6b Payment Date O <br /> Payment Type Invoice# Check# -Z Z.p 3 Receive By: 6C�- <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />