Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR MZI <br /> Corey Lee CHECK if BILLING ADDRESS <br /> FACILITY NAME Lee Property <br /> SITE ADDREss3852 & 3858 S. tockton T9 <br /> Street Number Direction MOurfleld AveAStreetName cityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 5521 13th St. <br /> c/o Gary Madsen Welty Engineering Street Number Street Name <br /> CITY Modesto STATE CA Zip 95354 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 526-1515 175-240-27 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME Or MAILING ADDRESS FAx# <br /> 407 W. Oak St. <br /> ( ) <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 An this form. <br /> I also certify that I have prepared this application anKDERAL <br /> the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE an laws. <br /> APPLICANT'S SIGNATURE: DATE: 3/7-7�/cJ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ F <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/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: Review Surface & Subsurface Contamination ReLfCLYMENT <br /> COMMENTS: RECEIVED <br /> APR 01 2019 <br /> r J/j�J N COUNTY <br /> `[ / <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P 1 E:276t) <br /> Fee Amount: Amount Paid Payment Date l <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />