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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Trailer Park 0 5 kO CLVO <br /> OWNER/OPERATOR <br /> Property Management Experts CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Cherry Lane Trailer Park <br /> SITE ADDRESS 11211 E Highway 26 Stockton 95215 <br /> Street Number Direction Street Name CI Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 200 W. Harding Way <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95204 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 465-5000 Engineered Septic System <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR David Welch <br /> CHECK If BILLING ADDRESS x <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 Z'P 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 ap lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar ,STA E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: — �O1 C'( T-PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGE h Su l QCT V\ I <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: <br /> COMMENTS: Please review the engineered septic system drawing and reports. A report review <br /> of$465 is attached. X131 - z/ /�� RECENED <br /> 121--r-In,27 � SEP 3 2pp4 <br /> APPROVED BY: EMPLOYEE M116 �fz <br /> DATE: S I N Er9N <br /> ASSIGNED TO: EMPLOYEE M DATE. <br /> Date Service Completed (if already completed): SERVI E CODE: 5-22—2— P 1 E: <br /> Fee Amount: �� Amount Paid 11 { S OD Payment Date R 3 D <br /> Payment Type ✓ Invoice# Check# I �3S Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />