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V i <br /> SAN JOAQUu, COUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ,5WOO CIS-7 0,S- <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Mr. and Mrs- Stan Robertson <br /> FACILITY NAME <br /> NEC 1-5 and West Linne <br /> SITE ADDRESS 2625&2777W Linne Tracy 95304 <br /> Street Number Direction Street Name citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Banta Rd <br /> 27337S. Street Number Street Name <br /> CITY STATE ZIP <br /> Tracy California 95376 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209)914-1392 239-210-08 & -09 PA 05-427 <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS x <br /> Nancy Ro-,tjlpk <br /> BUSINESS NAME PHONE# EXT. <br /> Neil 0. Anderson and Associates, Inc- ( 209)367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (2 )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 1 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: _ �,. DATE: :Z- <br /> PROPERTY i BUSINESS OWNER❑ O ERATOR i MAN GER OTHER AUTHORIZED AGENT 0 ems, S `� <br /> If APPL/CANT 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: -2-1 0/666 �W► �p,G�.t y+. �`t7 <br /> sqN J 2006 <br /> C� N�CT y 0 PAR MFN ry <br /> T <br /> APPROVED BY: EMPLOYEE#: O DATE: 3 <br /> S <br /> ASSIGNED TO: ` ��y t'Q EMPLOYEE#: 0 DATE: <br /> Date Service dompleted (if already completed): SERVICE CODE: Z-�— P/E:o26o7— <br /> Fee Amount: Amount Paid s d u Payment Date y D(o <br /> Payment Type Invoice# Check# 2 5 Received By: N <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />