Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 9krw, -? <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Nhon Tan Vien <br /> FACILITY NAME <br /> SITE ADDRESS 7101 . State Route 12 Lodi 95240 <br /> Street Number DEirection Street Name citv Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 16160 N. Moore Road <br /> Street Number Street Name <br /> CITY Lodi STATE CA ZIP 95240 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 049-130-52&53 PA 1600024 <br /> (209 1 482-3679 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Mike Toy CHECK if BILLING ADDRESSLAk <br /> BUSINESS NAME PHONE# EXT' <br /> Dillon&Murphy 209 334-6613 <br /> HOME or MAILING ADDRESS FAx# <br /> P.O. Box 2180 <br /> (209 ) 334-0723 <br /> CITY Lodi STATE Ca ZIP 95241 <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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 FEDERA7�� <br /> APPLICANT'S SIGNATURE: O_ <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I MANA ER ❑ OTHER 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time I Is provided to me or <br /> my representative. <br /> AM AFIrl <br /> TYPE OF SERVICE REQUESTED: (� kft <br /> J I i S4 GLd•- 1 eU I� WC <br /> COMMENTS: <br /> 06 31 <br /> 2018 <br /> hTh pF�M �Y <br /> Z i �{ r <br /> ACCEPTED BY: / EMPLOYEE#: DATE: F[3 /41 <br /> ASSIGNED TO: �� EMPLOYEE#: DATE: `F 3 r <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: 'hot <br /> Fee Amount: 30,f Amount Paid 304 _ Payment Date g 3 t 1 (i <br /> Payment TypeInvoice# Check# ?2?�� Received By: Vk-1-4 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />