Laserfiche WebLink
SAN JOAQUIN COUNTY ENvIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SER6 CE REQUEST# <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> Ron Rnh'nsQn <br /> FACILITY NAME <br /> Ro inson Pro et <br /> SITE ADDRESS >>ass W State Route 12 Lodi <br /> Street Number DirectionStreet Name <br /> CRY zl Code <br /> HOME Or MAILING ADDRESS (N Different from Site Address) Riverpoint Drive <br /> 1108 Strwt Number Strt Name <br /> `.IT, STATE ZIP <br /> Lodi CA 95240 <br /> PHONE#I APN# LAND USE APPLICATION# <br /> (209 )334-5758 025-060-03 PA-04-488 <br /> PHONE#2 Ear. BOS DISTRICT LOCATION CODE <br /> I ) 1 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK N BILLING ADDRESS <br /> Nancy R. Kramer <br /> BUSINESS NAME PHONE# En. <br /> NP. 10 Andecson And AgSociates In(, ( 90Q)'497-'4701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way ( ) <br /> CITY 369$TATE ZIP <br /> Lodi CA 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 roe 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,Standar F / <br /> /APPLICANT'S SIGNATURE: , l f�tm—� DATE: 2110 07_ <br /> PROPERTY/BUSINESS OWNER RL OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT® t� <br /> /,ffAPPLICANT is not the BILLRVGPARTP proof of autharizadon 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 environmentausite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the San. time it is <br /> provided to me or my representative. (��•y� YME 1 <br /> TYPE OF SERVICE REQUESTED: �0Lit <br /> f :J/ K RE <br /> IV <br /> COMMENTS: / �7 FEg % 0 2 <br /> SAN 6JNIRONIME O ANT <br /> !i/"r � HATH DEPARTM <br /> APPROVED BY EMPLOYEE#: DATE: •Z 7�� rt <br /> ASSIGNEDTO: �. --nla4Zz--it-� EMPLOYEE#: — DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 52 Z P 1 E: U <br /> Fee Amount: Amount Paid 16 190U o Payment Date ',.-'D10-2 <br /> Payment Type ��- Invoice# Check# / Received By: ?� <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />