Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT AUG 2 4 2016 <br /> SERVICE REQUEST ^�.. - <br /> Type of Business or Property FACILITY ID# M� <br /> Trucking CA 0UO3� I SERVICE REQUEST# <br /> OWNER/OPERATOR }� <br /> Steve v 1`lC/HIE/CK If BILLING ADDRESS n <br /> FACILITY NAME KIUdt Trucking <br /> SREADDRESS 1126 <br /> E Pine Street Lodi <br /> Street Number fraction 95240 <br /> HOME or MAILING ADDRESS (lf Different from Site Address) street Name Cit <br /> zi coae <br /> PO BOX 166 <br /> CITY Street Number beat Name <br /> Lodi STATE Ca ZIP <br /> PHONE#1 95241 <br /> En, <br /> 1 209)466-8969 APN# LAND USE APPLICATION# <br /> PHONE#2 Exr <br /> ( ) BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> ®REQUESTORMegan Mitchell CHECK If BILLINGAODREy1.MEElite IV contractors PHONE# Exr. <br /> ING ADDRESS 209 461-6337 <br /> 2535 Wigwam Dr Fax#on ( 209) 461-6342 <br /> STATE Ca Z"95205 <br /> BILLING AC/CNOIVLEDCEMENT: 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 /> 1 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: o�yivs <br /> DATE: 8/24/2016 <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER ❑ <br /> OTHER AUTHORIZED AGENT[R_ Q{fge Assistant <br /> {JAPPL/CANT is not rhe B1LLINC PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,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 me or my representative. <br /> TYPE OF SERVICE REQUESTED: S RFC FNT <br /> COMMENTS: <br /> _v .4p� <br /> N <br /> oeAae. <br /> A <br /> ACCEPTED BY: YVIIn O,v I7I/,( wO(I EMPLOYEE / <br /> 111►I Vl rJlf' Gt DATE: � ')tt Ile <br /> ASSIGNED TO: � I.- VEMPLOYEE#: <br /> '1 DATE: <br /> Date Service Completed (if already Completed): <br /> SERNCE CODE: SG qbPIE: <br /> Fee Amount: A III—I YYUU CVI <br /> "I I Amount Pai <br /> Payment Type �7 Od Payment Date z�2 <br /> /6-_ Invoice# Che # //// <br /> ��Z'Z. Received By: <br /> EHD 48-02-025 <br /> REVISED 11/1712003 SR FORM(Golden Rod) <br />