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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> sK oo+'�9z k:)- <br /> OWNER/OPERATOR <br /> Iris Moffat CHECK If BILLING ADDRESS <br /> FACILITY NAME Moffit Property <br /> SITE ADDRESS 25744 1 E. Lone Tree Rd. Escalon 95320 <br /> Street Number ed <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Sheet Name <br /> CITY STATE ZIP <br /> PHONE#t En. APN# LAND USE APPLICATION# jvi <br /> (209)838-2000 1 229-080-75 Unassigned <br /> PHONE#2 E%T- BOS DISTRICT LOCATION CODE <br /> ( 209) 604-0088 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Nancy Rosulek CHECK If BILLING ADDRESS® <br /> BUSINESS NAMEPHONE# <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME Of 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: 2- <br /> PROPERTY/Busmss <br /> PROPERTY/BUsmss OWNERO Or LRATOR/MAI \GER ❑ OTHER AUTHORIZED AGENT O e: a: ` r- v. T <br /> V'APPLICANT is nor the BJLLWG PARTY roof of authorization to sign is required TirleP, y <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the prop <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite t <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and dFA:8S P time I S <br /> provided to me or my representative. l., ,,1 ` 4 <br /> TYPE OF SERVICE REQUESTED: SOII Suitability Stud FN� <br /> QQ <br /> COM NTS: D " FArr- <br /> 3/W/' �? rp,� it- c t Ci t� w .c ire �� �' '! cTMEM <br /> � .31 0(r <br /> APPROVED BY: D L-I L/E 1 F PLOYEE#: U/3 Z( DATE: <br /> ASSIGNED TO: -TA l CJ f0(J✓Ells EMPLOYEE#: YG<f j DATE: LIZ Lf ZLf <br /> Date Service Completed (If already completed): SERVICE CODE: S zy P/E: 2-G c,/ <br /> Fee Amount:q 1 k-& -�,U Amount Paid (o d J Payment Date Z 2 <br /> Payment Type L/ invoice# Check# ao l) Received By: C, <br /> EHD 48-0t-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />