Laserfiche WebLink
SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# [!� 00,� Sq3 <br /> ICE REQUEST# <br /> Rosethal Building 6 <br /> OWNER OPERATOR BILLING PARTY <br /> Rosenthal Triiqt- <br /> FACILITY NAME <br /> Rosenthal <br /> SITE ADDRESS q American Streeet <br /> 24 I Street Numbs Sheth NM Name TTP- Suite% <br /> Mailing Address (If Different from Site Address) <br /> C/O Bank <br /> Crry STATE ZIP <br /> Stockton CA 95201 <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> ( ) 929-1526 <br /> PHONE#Z Er. BOB DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY G <br /> Advanced Geo Environmental <br /> BUSINESS NAME PHONE# Er. <br /> 837 Shaw Road R09 467-1006 <br /> MAILING ADDRESS FAX# <br /> Cm Stockton STATE CA ZIP 95215 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated wltn this project 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 wim all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL lam. y'f tII'- � <br /> APPLICANT SIGNATURE: I A.I V,� � t i L'Y'/ DATE: -9/7 ��G <br /> PROPERTY/BUSINESS OWNER G OPERATOR I MANAGER OTHER AUTHORIZED AGENT <br /> NAPauc is not B/ Naz'proof ofwNodudon to sign isnpukW V 'TWe <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH ONISICN as soon <br /> as it is available and at the Same time d is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> Remo <br /> COMMENTS: PAY N4 E <br /> REC'EIVEL <br /> MAR 8 E; <br /> SAN JOAOUIN COUNTP <br /> �0,HEALTH SERVICES <br /> "'r'TA!.HEALTH OT VISInr, <br /> INSPECTOR�s SIG CONTRACTORS SIGNATURE: <br /> FFnGVE'u EMPLOYEE#: <br /> gool DATE: <br /> ASSIGNED TO: S EMPLOYEE#: Q DATE: <br /> Date Service Completed (if already completed): SERVICECODE: 3 PIE: <br /> Fee Amount: Amount Paid 6 Payment Date <br /> Payment Type Invoice# Check# I g' Received By: - <br />