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SAN,JOAQUIIN 7UNTY ENVIRONMENTAL HEALTH T PARTMENT t..Y •... �� h~ SERVICE REQUEST � U4.v Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER/OPERATOR Mr. Jim Burnett CHECK If BILLING ADORESS❑ FACILITY NAME Burnett Property SITE ADDRESS 21461 E. Kettleman Ln. Lodi 99k(6 Street Number I Direction I Street Name city Zip Ceti. HOME Or MAILING ADDRESS (If Different from Site Address) 2220 N. Highway 99 _ Street Name CITY Acampo oa \STATE CA ZIP 95220 PHONE#t Eay. APP#C j/ LAND USE APPLICATION# (209)368-3922 -220-05 & -06 PA-02-086 PHONE#2 Exr. OS DISTRICT LOCATION CODE ( ) CONTRACTOR REQUESTOR REQUESTOR Abby Racco CHECK IT BILLING ADDRESS® BUSINESS NAME PHONE# Ext. Neil O. Anderson & Associates Inc. 209 367-3701 HOME Or MAILING ADDRESS FAX# 902 Industrial Way (209 )369-4228 CITY Lodi 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. 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,Standards,S' TE and FEDERAL laws. APPLICANT'S SIGNATURE: Neil O.Anderson&Assoc., Inc. DATE: V I PROPERTY/BUSINESS OWNER 13 OPE TOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Consultant IfAPPLICAAT 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: COMMENTS: �-ct7_ , RECEIVED 5 MAY 1 9 2005 SAN JOAQUIN COUNTY ENVIRONMENTAL APPROVED BY' EMPLOYEE M TE: ilcmrf ASSIGNED T EMPLOYEE M DATE: Date Service Completed (if already completed): I SERVICE CODE: 27 Pig: Fee Amount: Amount Paid 3?� U Payment Date Payment Type Invoice# Check# f (0 2 4 S Received By: EHD 48-01-025 ,. SERVICE REQUEST FORM REVISED 6-5-02 �L� •W 3 0 �;