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SAN JOAQU-. 4 OUNTYENVIRCtME'fTALHEALTHLAPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# X200 4 2-54,S- OWNER/ S4.SOWNER/OPERATOR CHECK If BILLING ADDRESS Mr- and Mrs. Stan Robertson FACILITY NAME NEC 1-5 and West Linne SITE ADDRESS 2625&2777W Linne Tracy 95304 Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Banta Rd 27337S. Street Number Street Name CITY STATE ZIP Tracy California 95376 PHONE#1 ExT• APN# LAND USE APPLICATION# �J'_ U (209)914-1392 239-210-09 uaa&&kPed rnS 0o I o?7 PHONE#2 ExT• BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESSNanny Ro-,ijlpk X BUSINESS NAME PHONE# ExT• Ne*l 0- Andpi-scin and Associates, Inc. ( 209)367-3701 HOME or MAILING ADDRESS FAX# 902 Industrial Way (20 9) -4228 CITY Lode STATE CA ZIP 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. 1 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,Standards,STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: to PROPERTY/BUSINESS OWNER[3 O ERATOR/MANA ER ❑ OTHER AUTHORIZED AGENT 0 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: `.c�t q c.ti S S u -a A C �' �'T'� ^��n� C( T COMMENTS: �CI r .�n1tN�T ,`��.� v� JUN 2 2005 �U M�tJ lj 1��`r 3k, SANOly AQUIMEO N D7 Zj M,IN�j F{r'S (rJ'� ME APPROVEDBY: EI EMPLOYEE#: �? 2 DATE: Z /� ASSIGNED TO: �/ O r EMPLOYEE#: T(—O c)o DATE: Date Service Completed (if already completed): SERVICE CODE: ,'3�,$ P/E: 3 Fee Amount: & Amount Paid �(' Payment Date S Payment Type Invoice# Check# 1-7 F� Received By: EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02