Laserfiche WebLink
SAN JOAQUIteCOUNTY ENv4ROT/4ENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 004-I E <br /> OWNER/OPERATOR <br /> CHECK IT BILLING ADDRESS <br /> FACILITY NAME <br /> 275 East Homestead Road Pro eLl <br /> SITE ADDRESS 275 E Homestead Road Tracy 95304 <br /> Street Number Direc I I Street Name cay zip Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 26662 San Jose Road <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Tracy <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> ( ) 239-160-03 & 239-160-04 PA-04-44,,5 <br /> PHONE#I BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESSE] <br /> Dave Wplrh <br /> BUSINESS NAME PHONE# E'n' <br /> Neil 0 Anderson and Assoc'atpq Inn 19021367-3701 <br /> HOME or MAILING ADDRESS FAx# <br /> 2 Industrial Way (209)369-4228 <br /> CITY Lodo <br /> 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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards and FEDERAL laws. ( t <br /> APPLICANT'S SIGNATURE: l DATE: C� l <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Consultant <br /> if APPLICANT is not the BILLING PARTY proof of authorization to sign is required rime <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 available and at the same time it is <br /> provided to me or my representative. <br /> TWE OF SERVICE REQUESTED: .SOI 5 Swb l S <br /> COMMENTS: �l <br /> Please review the following Soil Suitability Study. We have attach tt$;S€ d�B'�giew ff'�e/pf <br /> $186. If you have any questions please call. FEB <br /> Dave ,IG " 8 2005 3U <br /> I l <br /> 11r,5 SAN J <br /> JOAQUIN COUNTY ..LI <br /> ENVIRCIp��.,' <br /> APPROVED BY. - EMPLOYEE#: / fl D cwl Q� <br /> ASSIGNED TO:r7—trY_ trj <br /> EMPLOYEE#: V DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: JY Z 4- P 1 E: , <br /> Fee Amount: Amount PaidY� -- Payment Date -- <br /> PaymentType v Invoice# Check# 0 Received By: <br /> EHD 4"1-025 SERVICE REQUES` <br /> REVISED 6-5-02 <br />