Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRVN�E'4TAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> LT.�57�� <br /> OWNER/OPERATOR <br /> Mr. Ron McManis CHECK If BILLING ADDRESS <br /> FACILITY NAME Browns Lake Ranch <br /> SITE ADDRESS 18700 E. River Rd. Rip <br /> 95366 <br /> on <br /> Street Number Direction 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#1 EXT. APN# LAND USE APPLICATION# ;4 <br /> (209)559-1186 245-220-21 Unassigned <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Tina Cheney CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <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 wit:l 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: (NLA DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGEyd OTHER AUTHORIZED AGENT❑ <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 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 <br /> REQUESTED: <br /> COMMENTS:COMMENTS: <br /> N <br /> 66 /�C,,4e*V i/ ( <br /> RECEIVED <br /> a , a <br /> JAN 2 4 2006 <br /> SAN JOACION COUNT`( <br /> if qF414AL <br /> APPROVED BY: EMPLOYEE#; DATE:H PARTMENT <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> l <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: / b3 <br /> Fee Amount: (pl 6b Amount Paid 'fj YL,0-0 Payment Date <br /> Payment Type l%' Invoice# Check# 1-733.S— Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />