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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property <br /> CHECK if BILLING ADDRESS■/r.� <br /> OWNER I OPERATOR Kent Raverty <br /> FAcILITYNAME Raverty Property <br /> Acampo 95242 <br /> SrrE ADDRESS 100 E Taddei Road ty Z; coae <br /> Street Number Direction <br /> Street Name CI <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> STATE ZIP <br /> CITY <br /> Exr. APN# LAND USE APPLI ON# <br /> PHONE#1 b' 013-130-23 ips - 002-60 & Ul" <br /> (Zo 1 <br /> Exr. n7i_—Ifft <br /> N CODE <br /> PHONE#2 I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R>=QUESTOR � CHECK if BILLING ADDRESS 0] � ] <br /> PHONE# EXT. <br /> BUSINESS NAME Neil O. Anderson &Associates Inc. 209 ) 3 7-37 1 <br /> FAx# <br /> HOME Or MAILING ADDRESS (2091169-4228 <br /> 902 Industrial Wa STATE CA <br /> Zip 95240 <br /> CITY "Lodi <br /> KNroperty or business owner, operator or authorized agent of same, <br /> BILLING ACOWLEDGEMENT: I, the undersigned p <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 and FEDERAL laNYS. <br /> DATE• <br /> APPLICANT'S SIGNATURE: <br /> f�.� �• ❑ OTHER AUTHORIZED AGENT❑ <br /> PROPERTY/BUSINESS OWNER �PERATOR I MANAGER <br /> Title <br /> If APPLICR. is not the BILLING P t�proof of authorization to sign is required <br /> erty located at the <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the prop <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 /> FA AA RN <br /> TYPE OF SERVICE REQUESTED: G"- . .k �_ -` �•. 1 ':11 G, I V 1D <br /> COMMENTS: <br /> 1711to <br /> SEC 19 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> I EMPLOYEE#: DATE: <br /> APPROVE BY: <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: n`' <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: 2 P i E: .. <br /> ,r , Amount Paid Payment Date <br /> mount: bFee `'L v <br /> Check# Received By: <br /> Payment sype � Invoice# s 3 <br /> SERVICE REQUEST FORM <br /> EHD 48-01-025 <br /> REVISED 6-5-02 , <br />