Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FFACIUTY <br /> ness or Property FACILITY ID# <br /> SERVICE REQUEST# <br /> ERATOR �� <br /> Verne Schultz <br /> CHECK If BILLING <br /> SITE ADDRESS <br /> 31103 Grooms Road Oakdale 95361 <br /> swat Number r .e eta a <br /> HOME Or MAILING ADDRESS (If Different from Site Address) D C de <br /> 31146 East Lone Tree Road <br /> CITY SVeet Number Street Name <br /> Oakdale STA UA zip 95361 <br /> PHONE#1 ECT. APN# <br /> LAND USE APPLICATION 209) 847-0516 # <br /> 2o7-2ao-o3 ,, -06- 00 31 Y 'A,g <br /> PHONE#Z E%T. <br /> ( I BOB DISTRICT OCpT10N CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Tina Cheney CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# En. <br /> .Neil 0. Anderson & Associates Inc. 9 20367-3701 <br /> HOME Or MAILING ADDRESS j20 <br /> 902 Industrial Way12091369-4228 <br /> CITY Lodi STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 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. --77��-- <br /> APPLICANT'S SIGNATURE: f / mgt r/VDATE: <br /> PROPERTY/BUSINESS OWNER E3 ( 'OTHERAUTHORMZOPERATOR/MANAGER ED AGENT IP <br /> If APPLICANT is nor the BILLING PARTY proof ojauthorizadon to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 t0 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: 7 <br /> 7/!5/oG 2��o,f rev/cr,.l (30 ,t <br /> MAY 2 5 2006 <br /> SAN JOIgoNMENTAI. <br /> APPROVED BY: EMPLOYEE I-T ATE: <br /> ASSIGNED TO: EMPLOYEE#: U DATE: <br /> Date Service C mpleted (if already co pleted): SERVICE CODE: S' P/E: .23 <br /> Fee Amount: Amount Paid D'!p + Payment Date - <br /> Payment Type Invoice# Check#�' vl L/sJ Received By: . <br /> EHD 48-01-025 t SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />