Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 15a O'A v1 1 <br /> OWNER I OPERATOR <br /> Octavio Medina CHECK If BILLING ADDRESS <br /> FACILITY NAME Medina Property <br /> SITE ADDRESS 5850 E. Ashley Ln. Stockton 95212 <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 5830E. Ashley Ln. <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95212 <br /> PHONE#1 EXr. APN# LAND USE APPLICATION# <br /> (209) 470-9028 085-110-76 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak Geo Environmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <br /> CITY Lodi STATE CA ZIP 95240 <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 JOAQtma <br /> COUNTY Ordinance Codes,StandarA STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: _ DATE:_f— 2-2-- 1 e/ <br /> PROPRR'rv/.RUSINESS OWNER[& OPERATOR/MANAGER ❑ R AUTHORIZED AGENT❑ <br /> If APPLICANT 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/s' a assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and attltg'('AP '}ie it is <br /> provided to me or my representative. /��77 ��'�ywl <br /> TYPE OF SERVICE REQUESTED: Review Nitrate Loading Study J F <br /> COMMENTS: Sq✓o <br /> yZ ZQ19 <br /> et YLF,oNr1NIY <br /> MFti'T <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: b EMPLOYEE#: DATE: <br /> Date Service C mpleted (if already completed): SERVICE CODE: P1 E: <br /> Fee Amount: Amount Pa' 3 ,bD I Payment ate <br /> Payment Type Invoice# C Ck# !J�l/j�� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />