Laserfiche WebLink
fi <br /> SAN JOAQU COUNTY ENVIRONMhNTAL HEALTHpA <br /> RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID# SERVICE REQUEST# <br /> 1 OWNER 1 OPERATOR < /-7 OLf <br /> I <br /> FACILITY NAME CHECK if BILLING® <br /> Dart Pro ert <br /> SITE ADDRESS 13299 <br />' n <br /> Street Number irection Lodi 95242 <br /> HOME or MAILING ADDRESS (If Different from Curry Avenue Site Address) tree Na e <br /> CI Zi Code <br /> t <br /> CITY Street Number <br /> treat Name <br /> PHONE#1 Exr <br /> t } AP—P STATE ZIP <br /> LAND USE APPLICATION# <br /> PHONE#2 061-140-05 PA-04-288 <br /> t } I30S DISTRICT LOCATION CODE ' <br /> REQUESTOR CONTRACTOR/SERVICE REQUESTOR <br /> BUSINESS NAME CHECK If BILLING <br /> # <br /> HOME or MAILING ADDRESS PHONE Fes, <br /> 0 I dustri I W FAx# - <br /> CITY <br /> STATE <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> ZIP <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 JOAQU <br /> COUNTY Ordinance Codes,Standards,STATE and FEDE <br /> ws. <br /> APPLICANT'S SIGNATURE: i <br /> DATE: Z� <br /> PROPERTY/]BUSINESS <br /> USINESS OWNER D � <br /> /MANAGER 0 OTHER AUTHORIZED AGENT❑ <br /> If/APPLICANT is not the BILLING p4RTY proof of authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the propelrty located at the I <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: SOIL Suitability Study/Nitrate Loadin (2f. dy Review <br /> COMMENTS: <br /> Please review the following Soil Suitability Study/Nitrate Loading Study. Mr.%"WED <br /> attach the service review fee of$465. If you have any questions please Cal <br /> Dave �3�� AR 2 2 2005 <br /> SAN i AQU1N COUNTY <br /> APPROVED BY' / NVIRO NM TA <br /> EMPLOYEE#: Cy []Dp <br /> ASSIGNED TO: <br /> I EMPLOYEE#: 1 <br /> DATE: <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid <br /> Payment Date <br /> Payment Type ,/ Invoice# �� <br /> Check# `g Received By: <br /> EHD 48-01-025 u � y,� 4r I� <br /> REViSED 6-5-02 QV'" SERVICE REQUEST FORM <br /> � I <br /> ye <br />