REMOVAL_2008 - Laserfiche WebLink

Home Browse Search

UHl\ JVH�V rl• <.V Ul\ -I 1L11 Y 11NVL\1r1G11 IHL xxG 1 Gl H1\l lIr G1\ 1 SERVICE REQUEST CONTRACTOR / SERVICE REVUr;al vcc W FACILITY ID # CHECK If BILLING ADDRESS® SERVICE REQUEST # Type of Business or Property COMMENTS: PHONE # EXT. BUSINESS NAME Neil O. Anderson &Associates Inc. 209 �3 APPROVEDBY: if BILLING ADDRESS OWNER / OPERATOR Bob Lee CHECK FACILITY NAME Hondo Company CITY Lodi SITE ADDRESS 6426 E Haight Road Lodi 95240 ZiCode Street Number Direction Street Name Clt HOME or MAILING ADDRESS (If Different from Site Address) PO Box 1007 Street Number Street Name CITY Woodbridge STATE ca ZIP 95258 PHONE #'I EXT' APN # LAND USE APPLICATION # ( 209) 369-8255 061-150 38 Cid Payment Date -� I6 PHONE#2 EXT ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REVUr;al vcc W CHECK If BILLING ADDRESS® REQUESTOR James Robinson TYPE OF SERVICE REQUESTED: S COMMENTS: PHONE # EXT. BUSINESS NAME Neil O. Anderson &Associates Inc. 209 367-37 APPROVEDBY: FAX # EMPLOYEE M HOME or MAILING ADDRESS 902 Industrial Wa ( 209 )369-4228 CITY Lodi STATE CA zip 95240 ASSIGNED TO: 1 r 1 A tf sam L BILLING ACKNOLEDGEMENT: I, the undersigned property or business owner, operator or authorize agen o , acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STAT nd FEDE laws. APPLICANT'S SIGNATURE: DATE: 9 8 PROPERTY/ BUSINESS OWNER❑ OPERAT R/MANAGER ❑ OTHER AUTHORIZED AGENT iJ Sr. Project Manager IfAPPLICANT is not the BILLING PAn7'r proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL LH DEPARTMENT as soon as it is available and at YlE,,same time it is provided to me or my representative. �qAl7,- TYPE OF SERVICE REQUESTED: S COMMENTS: NyOgQU/RO rhofp4 APPROVEDBY: EMPLOYEE M DATE: t/I /) EMPLOYEE#: S�O DATE: ASSIGNED TO: 1 r 1 SERVICE CODE: 3 P I E: Date Service Completed (if already completed): Fee Amount: Amount Paidrj Cid Payment Date -� I6 Payment Type / Invoice # Check # Z Received By: SERVICE REQUEST FORM EHD 48-01-025 REVISED 6-5-02