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SAN JOAQU ~OUNTY ENVIRONMENTAL HEALTI "PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# S ' ( c 7�5� OWNER/OPERATOR Rene Matson CHECK if BILLINGADDRESSE] FACILITY NAME Amoroas Inn and Gardens SITE ADDRESS 7889 1 E I Harney Lane Lodi95240 Street Number Direction Street Name Ci Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY Lodi, STATECalifornia Z'P 95240 PHONE#1 EXT. APN# LAND USE APPLICATION# (209))368-5658 1 061-133-28 SA-01-77 PHONE#2 EXT• BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR David Welch CHECK if BILLING ADDRESS BUSINESS NAME PHONE# EXT' Neil O. Anderson &Associates Inc. 209 367-3701 HOME or MAILING ADDRESS FAX# 22 Houston Lane ( 209)369-4228 CITY Lodi STATE CA Z'P 95240 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT 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,Stand AT and FEDERAL laws. j APPLICANT'S SIGNATUR 1DATE: PROPERTY/BUSINESS OWNER❑ —OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ If APPLICANT is not the BILLING PARTY,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 C;JVE �S'LI t'Tc f L f _S %�{�'� CJD �%�J�{✓� COMMENTS: Please review the addendum for the Soil Suitability S udy. A report review fee of$186 was requested by Mike Huggins. Mat McCart ctor (368-1222 and is our client. APPROVED BY: C L I L;f ( I�� EMPLOYEE#: ��3 2 DATE: 3 ASSIGNED TO: "1.6 EMPLOYEE#: DATE: / C,L s Date Service Completed (if already completed): SERVICE CODE: 5—L L PIE: C Fee Amount: ( lr( o'-L) Amount Paid Payment Date 3 Payment Type ,/ Invoice# Check# / �? , .r. Received By: EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02