Laserfiche WebLink
�11 ' . ` <br /> SAN JOAQUuiOUNTY ENVIRONMENTAL HEALTHIOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1 -51C0 D tlq9l� <br /> OWNER OPERATOR <br /> Ms. Patricia Knowles CHECK If BILLING ADDRESS <br /> FACILITY NAME Knowles Property <br /> SITE ADDRESS 16417 S. Victory Rd. Oakdale 95361 <br /> Street Number Direction treet Name CON Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 13661 Vallesy Home Rd <br /> Street Number tree[Name <br /> CITY STATE ZIP <br /> Oakdale CA 95631 n <br /> PHONE#1 E;7 APN# LAND USE APPLICATION# <br /> (209)847-2292 229-220 06 &-05 Unassigned <br /> PHONE#2 Ear. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco 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 (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 accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: )Ce 1j✓g;l 0. A&fM- /t ScYC• DATE: <br /> PROPERTY/BUSINESS OWNER❑ ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT L� <br /> lfAPPL/CANT is not the B(LL(NG PARTY proof of authorization to sign is require Tine <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: S k0-F,4G£ �6A2-.f-4z> me- PAYMENT <br /> COMMENTS: 1/1 6(p R <br /> `— <br /> NOV 2 3 Z0(5 TY <br /> t SAN JOAOUIN Co"" <br /> ENVIRONMENT' <br /> W�AITHDEPART ENT <br /> APPROVED BY: LyL v t ./ l EMPLOYEE#: 3 Z / DATE: it 23 aS <br /> ASSIGNED TO: UA-1v ® N E EMPLOYEE#: ��� DATE: It <br /> 2-3/of <br /> Date Service Completed (if already completed): SERVICE CODE: `j(S Pit: ".C)3 <br /> Fee Amount: g(p,� Amount Paid C-1) Payment Date I y3 <br /> Payment Type Invoice# Check# �`l�.o Received By: <br /> EHD 48-01-025 ( I SERVICE REQUEST FORM <br /> _ <br /> REVISED 6-5-02 ^ `�I <br />