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SAN JOAQUIN COUNTY ENVIRONMENTAi,HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> or 3 <br /> OWNER/OPERATOR <br /> Brad Goehring CHECK If BILLING ADORES <br /> FACILITY NAME Goehring Property <br /> SITE ADDRESS 21803 E. Kettleman Lane Lodi95240 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 505 <br /> Street Number Street Name <br /> CITY Clements STATE CA ZIP 95227 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 759-9463 053-220-08 ,v Z U 1 Ckl-s <br /> PHONE#2 EXT. BOS DISTRICT LOCATI C E <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Nancy Kramer CHECK If BILLING ADDRESS LW <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: 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 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: DATE: t'L/(,x <br /> PROPERTY/BUSINESS OWNER El O ERATOR/ AGER 13 ER AUTHORIZED AGENT[3 <br /> If APPLICANT is not the B LLING PARTY,proof of authorization 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 Inc or my representative. c <br /> TYPE OF SERVICE REQUESTED: Soil Suitability Study <br /> COMMENTS: <br /> �n 3 0 p 2007 <br /> L7EC 2 <br /> SAN JOAQUINE OTUNIN <br /> APPROVED BY: EMPLOYEE#: DATEIj LT "EPA <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �2 7j PIE: <br /> Fee Amount V"' Amount Paid t / 9 6. �� 1 Payment Date O� <br /> Payment Type Invoice# Check# �6q� Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />