Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> Gurmit Jhalli CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Jhalli Pro e <br /> SITE ADDRESS 17155 E Lone Tree Road Escalon 95320 <br /> Street Number Directlon Street Name city zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#f En. APN# LAND USE APPLICATION# <br /> ( ) 203-200-18 1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Tamara Woods CHECK If BILLING ADDRESS� <br /> BUSINESS NAME Neil O. Anderson & Associates, Inc. --FP—HONE Exr. <br /> 209 367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way 1 209) 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 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,S rATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OF ORATOR ANAGER ❑ OTHER AUTHORIZED AGENT INErnlronmental Consultant <br /> If APPLICANT 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 environmentaVsite 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 SERVICEREQUESTED: Surface Subsurface Contamination Report PAYME <br /> COMMENTS: </l 7 <br /> 17 FEB 17 2009 <br /> 11.b I /gyp 7,p SAN JO ftONIMENT IL <br /> HFEJU-Ty{OEPARTM <br /> ACCEPTED BY: EMPLOYEE#: DATE: iz 6:7 14 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SER CE CODE: &2,2 IP/E: <br /> Fee Amount: 0,P Amount Paid a I O — Payment Date -2/12 0 <br /> Payment Type ✓ Invoice# Check# 2 q L{ Received By: _ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />