Laserfiche WebLink
0 / ?600 e54 � <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST 0010 � - <br /> Type of Busin Roperty FACILITY ID# SERVICE REQUESTC- <br /> 4/- <br /> Z� <br /> OWNE TOR 00 <br /> Mr. Ron McManis CHECK if BILLING ADDRESS <br /> FACILITY E Browns Lake Ranch 40 <br /> SITE ADDRESS E. River Rd. 95366 <br /> Ripon <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# 06_a LO059 <br /> (209)559-1186 245-220-21 PA06-059 <br /> PHohE � EXT. BOS DISTRICT LOCATION DE <br /> InfC IUESTOR <br /> - CONTRACTOR / SERVICE REQ CHECK ifBILLINNGADDRESS® <br /> REQUESTOR Nancy Rosulek <br /> Ext. <br /> PHONE# <br /> BUSINESS NAME 209 367-3701 <br /> Neil O. Anderson & Associates Inc. FAX# <br /> HOME or MAILING ADDRESS (209 1369-4228 <br /> 902 Industrial Way <br /> STATE CA ZIP 95240 <br /> CITY Lodi <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, TATE and FEDERAL laws. ( C� <br /> APPLICANT'S SIGNATURE: MVV ("", DATE: �y1- 'J �.UL <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® -5�tl{-{ se/L1'1 e56 <br /> If APPLICANT is not the BILLING PARTY,pro 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 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: ry <br /> COMMENTS: 4`�`�f V,C2 <br /> SUN Zg 2006 <br /> SAN jo'''QJIP,) <br /> ENVIpC,, -Otl�'Ty <br /> HEALTy .,MENTAL' <br /> APPROVED BY: G EMPLOYEE#: DATE: <br /> ASSIGNED TO: `J QU� EMPLOYEE#: DATE: <br /> Date ice Completed (if already Completed): SERVICE CODE: 2 v 1 P/E: <br /> Fe -L Amount Paid 3 ( a ()C) Payment Date <br /> Payment ✓ Invoice# Check# a 1 3 � Received By: <br /> EHD 48-01-025 SERVICST FORM <br /> REVISED 6-5-02 40� <br />