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SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> SERVICE "QUEST <br /> S RVICE REQUEST# <br /> Type of Business or Property FACILITY ID# <br /> g ^���� I •/ CHECK U BILLINGADDRESSM <br /> OWNER/OPERATOR Ed Crai L ri <br /> FACILITY NAME Craig Property <br /> Clements 95227 <br /> SITE ADOREs20899East State Highway 12 Cit Zi cone <br /> Street Number Di ectlon <br /> HOME Or MAILING ADDRESS (If Different from Site Address) street Number Street Name <br /> STATE ZIP <br /> CITY <br /> Exr. APN IF LAND USE APPLICATION# 06- <br /> PHONE#1 <br /> (209 ) 334-9142 112 02 -030-07, 023-110-01, -11 ( ar— Di 1, 2, 3, 4 8 DR <br /> 1 Eai BOS DISTRICT LOCATION CODE <br /> PHONE#2 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Nancy Rosulek CHECK H BILLING ADDRESS <br /> BUSINESS NAME PHONE# En' <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME Or MAILING ADDRESS FAX# <br /> 902 Industrial Way (2091369 4228 <br /> CITY Lodi STATE CA ZIP 95240 <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 we or my business as identified on this form. <br /> 1 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• �p/g_ / %t�' /L1.L��j'y,Lr• DATE: 3-1? Ob <br /> PROPERTY/BUSINESS OWNER❑ OPERA /MANAGER ❑ OTHERAUT OR EDAGENT ��sri <br /> IjAPPLICANT is not the BILLING PARTY proojojauthdrization 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: Expedited SOII Suitability Stud 1 ' <br /> AM <br /> COMMENTS: IVE <br /> �jx�ri 411 ��.Q �v�� 3�a�/off BAR 2 <br /> 7 200 <br /> 3l�`J Sr v �n SA N✓OAQUIN CO <br /> hFALr o PMENTgL <br /> APPROVED / EMPLOYEE#: S�// DATE: O <br /> ASSIGNED TO: EMPLOYEE M5 b DATE: <br /> Date Se mple If (if alrea6y completed):/ �/b SERVICE CODE: �O,/ P I E: 9aa <br /> Fee Amount: 7a Q� Amount Paid J7a Payment Date��a7�O <br /> Payment Type rji-e-,F Invoice# Check# /apf"i Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />