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SAN JOAQUIN COUNTY RNVIRPNMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> K Dot-�9C) Irl+ <br /> OWNER/OPERATOR Roger Lang <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 27272 E. Lone Tree Road Escalon 95320 <br /> Street Number I DI, Street Name City zip Cod <br /> HO OOrTING <br /> �ADDRESB (If Different from Site Address) <br /> ✓!/�/(/� Sbeet Number Str..t Name <br /> CITY r�¢A ZIP9� <br /> PHONE 01 Ecr- APNIt LAND USE APPLICATION# <br /> ( 209) 531-5264 229-090-01 ?A- -p6- g 6 �otq <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Tina Cheney <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ems' <br /> Neil O. Anderson 8t 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 FEDE L laws. <br /> APPLICANT'S SIGNAT ME: DATE: 1'2-1K/OiC <br /> PROPERTY/BUSINESS OWNERyy OP11VTOR/MAVNAGER <br /> Zg OTHER AUTHORIZED AGENT 13 <br /> /f MPGCAmT is not the BILLmrG PARTY pr of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATIO . 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 environmentaUsite assessment <br /> information t0 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 8t Subsurface Contamination Rleport T <br /> COMMENTS: 1' /�2�t/D1" y.- <br /> DEC 0 6 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: EMPLOYEE#: (q C DATE: <br /> ASSIGNED TO: A S EMPLOYEE#: O DATE: <br /> Date Service Completed (if already c mpleted): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid 1 nPayment Date \2 d <br /> Payment Type � Invoice# Check# Z l s Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />