Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �� ��C��738 -Z <br /> OWNER/OPERATOR <br /> ERIZO VENTURES, DBA SKY ZONE CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME SKY ZONE <br /> SITE ADDRESS 5358 PACIFIC AVE STOCKTON 95207 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2070 FORI NO DRIVE <br /> Street Number Street Name <br /> CITY DUBLIN STATE CA ZIP <br /> 94568 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / <br /> CHECK If BILLING ADDRESS <br /> L)a::, D7f <br /> BUSINESS NAME HAGGERTY CONSTRUCf,16N INC PHONE# Ex'r. <br /> (209)47 -9898 <br /> HOME or MAILING ADDRESS 2474 WIGWAM DR #A FAX# <br /> CITY STOCKTON STATE CA ZIP 95205 <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-"he work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STALE and F DERALws. <br /> APPLICANT'S SIGNATURE:, . \l DATE: "/ <br /> , rI 1 ( '—�(� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTH AUTHORIZEDAGENT� 12 CONTRACTOR <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 ame time it is <br /> provided to me or my representative. MF <br /> TYPE OF SERVICE REQUESTED: Y) (ate G I->rz� �eC �Veh <br /> COMMENTS: 2015 <br /> SAN NV RQOUIN COU <br /> HEALTH pEpgNR AJ. <br /> ACCEPTED BY: EMPLOYEE#: DATE: ';-/I <br /> IC7 <br /> ASSIGNED TO: EMPLOYEE#: DATE: (1 <br /> Date Service Completed (if already completed): `tet SERVICE CODE: i�2 P 1 E: <br /> Fee Amount: ,� �_ Amount Pakr,53 Dl] I <br /> Payment Date /2-//, <br /> Payment Type Invoice# Check# �2 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />