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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Terry Hull, Hull Family Properties CHECK If BILLING ADDRESS <br /> FACILITY NAME Cherry Lane Mobile Home Park <br /> SITEADDRESS 11225 EHighway 26 Stockton 95215 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 200 W. Harding Way <br /> Street Number Street Name <br /> CIM Stockton STATE CA ZIP 95204 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209)644-6401 C M - ( <br /> PHONE#2 EXT. BOS DISTRICT L LOCA lNWCODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RECtUESTOR Tammy Woods for David Welch CHECK if BILLING ADDRESS )13 <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 /> CIM 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 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 andel FEDERAL laws. /) <br /> APPLICANT'S SIGNATURE: jli/�UG� J�V DATE: l v <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El �dloli <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: Septic System Plan Review `i RE NA Ep <br /> COMMENTS: ` J Cf <br /> �d�� � pEC 1 2007 <br /> f1 }lc G(t/2 SAN JOAQ IMEN fP" <br /> 01 <br /> PARTMENT <br /> APPROVED BY: �_i V'£ C 4 EMPLOYEE#: C) ?�`Z DATE: l2 <br /> ASSIGNED TO: 6, 4 EMPLOYEE#: 1� G- C' DATE: i L -7 <br /> Date Service Completed (if already Completed): SERVICE CODE: S Z Z� P/E: 2 <br /> Fee Amount: CAL) Amount Paid Payment Date {a_ [tL_O <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />