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SAN JOAQUIN COUNTY ENVIPPNMEN'TAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#FSERVICE REQUEST# <br /> 11 �d20ro y,�-vso <br /> OWNER/OPERATOR Ms. Iris Moffit <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Moffit Property <br /> SITE ADDRESS 25744 1 E. Lone Tree Rd. Escalon 95320 <br /> Street Number 'rection Street Name CIN ZIP Cod <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE# Eii' APN# LAND USE APPLICATION <br /> (209)838-2000 229-080-75 Unassigned V�f <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( 209) 604-0088 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco <br /> CHECK If BILLING ADDRESSID <br /> BUSINESS NAME PHONE# En' <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209)369-4228 <br /> CITY Lodi STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or autborized 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, ATE and FEDERAL laws./� // 1 <br /> APPLICANT'S SIGNATURE:��g N.U� O /7/t s�'t Sad' DATE: �/Z�/ 2�"/'14��� y <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/MANAGER O OTHER AUTHOmzED AGENT ( A—Akl4z'/VL.T <br /> ffAPPLICANT 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 environmentallsite 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 SERVICE REQUESTED: T <br /> �: �����L �/�,r`y /'�,,.�('� �� FN <br /> COMMENT� �,-` <br /> lr 520 <br /> �p SAN UOA <br /> 2'7 �/ /� ^" NF.STH EpgR� Ivry <br /> APPROVED BY: t/ EMPLOYEE#: � DATE:l, <br /> /1 / <br /> ASSIGNED TO: EMPLOYEE III: DATE: <br /> Date Service Completed (H already completed): SERVICE CODE: P 1 E: 09 <br /> Fee Amount: ( � `f' Amount Paid Payment Date \7_ ( 510S <br /> Payment Type Invoice# Check# \ \ w Received By: �4 Fr- <br /> EHD 45-01-025 SERVICE REQUEST FC <br /> REVISED 5-5-02 <br />