Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMF iYTAL HEALTH DEPARTMENT <br /> SERVILI"+QUEST <br /> Type of Business or Property FACILITY ID# //S''ERVICE REQUEST# <br /> (L <br /> OWNER/OPERATOR <br /> Luis G. Viramontes CHECK if BILLING ADDRESS® <br /> FACILITY NAME <br /> SITE ADDRESS 15709 N. Tretheway Roadcess s Lodi <br /> Street Number Direction Street Name t� ft:Ilutl Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 407 Sparrow Lane <br /> Street Number Street Name <br /> CITY Lodi ST t$1 zip95240 <br /> PHONE#1 EXT. APN# LANID.,USE APPLICATION# <br /> ( 209) 518-7373 051-200-33 <br /> PHONE#2 EXT. BOS DISTRICT LOCATIO CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Tamara Woods 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 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 ac. e with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY i BUSINESS OWNER[I OPERATOR/MANAGER ❑ 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, 1,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: Surface Subsurface Contamination Report RECp <br /> MEN T <br /> COMMENTS: tog- NOV s 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: L t`_ f `,', I P 74 EMPLOYEE#:0 ( DATE: I' (7 — 0 f' <br /> .2 a <br /> ASSIGNED TO: D� / EMPLOYEE#: 5 7� DATE: /I_ C <br /> Date Service Completed (if already completed): SERVICE CODE: 2, I � I P 1 E: �(� Co <br /> -9 1Fee Amount: I a Amount Paid i!i Payment Date 11 D <br /> Payment Type V, Invoice# a �_. Check# 1 Received By: <br /> Ilk- <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />