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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEMT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -71( <br /> OWNER/OPERATOR Roger Lang <br /> CHECK If BILLING ADDRESS 10 <br /> FACILITY NAME <br /> SITE ADDRESS 27272 E Lone Tree Road Escalon 95320 <br /> Street Number Direction Street Name CIW Zi,Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 546 Street Number Street Name <br /> CITY Escalon STATE CA ZIP 95320 <br /> PHONE#1 E[r. APN# LAND USE APPLICATION# <br /> 1209) 531-5264 229-090-01 /f -G� / - 6 � <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> 1 ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Nancy Kramer <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ezr <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 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 al FEDERAL laws. �J <br /> APPLICANT'S SIGNATU�pRRE: O 7 <br /> DATE: oc -���" <br /> to <br /> PROPERTY/BUSINESS OWNER ERATOR/"Y NAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /fAPPLic4iVT is not the B7LL1NG PiIR 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 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: SOH Suitability Study PAYME <br /> COMMENTS: 7 `�,/ / ., <br /> f y � FEB 1 5 2007 <br /> SANENVIRON) COUNTY <br /> {%li (� HEALTH DEPARTMENT <br /> APPROVED BY EMPLOYEE#: DATE: ZAJ 6 <br /> ASSIGNED TO: S O a O S MPLOYEE#: I DATE: <br /> Date Service Completed (if already comple[ d): SERVICE CODE: 2_2 PIE: 2(,0 <br /> Fee Amount: c) Amount Paid 1 ; cl a 1) f). Payment Date /s O <br /> Payment Type Invoice# Check# 1".7C) Re eived By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />