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SAN JOAQUi,, COUNTY ENVIRONMENTAL HEALTH 1JEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST S <br /> S+�CJa I�-�� <br /> 44 <br /> OWNER/OPERATOR Juanita and Dean Bennett CHECK If BILLING ADDREss❑X <br /> I <br /> F <br /> FACILITY NAME Bennett Property <br /> SITE ADDRESS 16880 E. State Route 88 Lockeford <br /> reet <br /> StNumber Irectfon Skeet Name Ci Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 713 West Kettleman Lane <br /> Street Number Skeet Name <br /> CITY Lockeford STATE CA ZIP 95240 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (209)334- 1717 019-180-31 & 30 PA-05-324 <br /> PHONE#7 Exr. BOS DISTRICT LOCATION CODEtill i <br /> I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Nancy Rosulek <br /> ' CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT• <br /> Neil 0. Anderson & Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209 )369-4228 <br /> CITY STATE$TATE CA zIP 95240 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> ackno:vledge 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 and FEDERAL la <br /> APPLICANT'S SIGNATURE;-- <br /> l <br /> PROPERTY/BUSINESS OWNER❑ Z OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required % Titt e <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 HEALTm DEPARTMENT as soon as it is available and at the same time it is <br /> s <br /> provided-to.me or my representative. <br /> TYPE OF SERVICE REQUESTED: CEN ED <br /> COMMENTS: 2 �J`I'J <br /> Xe <br /> SAM JOAQUIN CO At <br /> NMEN <br /> � <br /> i <br /> 64 ENVIso SME T <br /> H DE.PAFt <br /> HEALT t <br /> i <br /> APPROVEDBY: ��ttJ ce�4 EMMOYEEM �?� Z DATE: <br /> ASSIGNED TO:. EMPLOYEE#: DATE: <br /> Date Sery a GO pleted (if already completed]: SERVICE CODE: Jr cT Z.y P!E: �� p <br /> Fee A oun#: ,t3U Z TA <br /> mount Pai Payment Date \\ b s <br /> Pay ent Type v Invoice# Check# 3 S tA D Receiv d By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br /> j <br /> i �� r <br />