Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ManKLf <br /> OWNER/OPERATOR <br /> Family Dollar Store, INC. CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Family Dollar <br /> SITE ADDRESS Jackson Ave. Escalon 95320 <br /> 2043 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Manroe Rd. <br /> 10301 Street Number Street Name <br /> CITY Matthews STATE NC ZIP 28105 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 704)847-6961 227-260-31 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Fahmida Rashid, Authorized Agent CHECK if BILLING ADDRESS <br /> BUSINESS NAME Permit Advisors PHONE# EXT. <br /> ( 310) 275-7774 <br /> HOME or MAILING ADDRESS 8370 Wilshire Blvd., STE 330 FAx# <br /> CITY Beverly Hills STATE CA ZIP 90211 <br /> BILLING ACKNOWLEDGEMENT: I, 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: 3 <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT)i Ciy_�� <br /> IfAPPLICANT is not the BILLING 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 availabl Vl1 r 01Kit is <br /> provided to me or my representative. 1,GG 1 V <br /> TYPE OF SERVICE REQUESTED: (- <br /> 04� As- <br /> COMMENTS: � �� MAR 15 20!8� <br /> �9 ® 1EINVIRONNIENTAL HEALTH <br /> ✓b. ��f� DIEP.kRTNIENT <br /> ti�CN�tRo�I�C <br /> R <br /> us" <br /> Ty . oU <br /> oFA,gR <br /> ACCEPTED BY: P� 7- EMPLOYEE#: DATE: <br /> ASSIGNED TO: - EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: _` t>;S Amount Pai �$�-v(] Payment Date u / g <br /> Payment Type Invoice# Check# 9/u Recei�ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 Przz c^f f 3s 00 L` -5� <br />