Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 OPERATOR <br /> Super Store Industries CHECKM BILLING ADDRESS <br /> FACILITY NAME Super Store Industries <br /> SITE ADDRESS 16888 McKinley Avenue Lathrop 95330 <br /> Stmat Number Street Name C ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number at1 Neme <br /> CITY STATE ZIP <br /> PHONEYt Ex , APN# LAND USE APPLICATION It <br /> (209 ) 858-3384 198-160-26 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Michael Bowery <br /> CHECK if BILLING ADDRESS <br /> PHONE# <br /> BUSINESS NAME Krazan & Associates, Inc. ( 559 *' <br /> 559 348-2200 <br /> HOME Or MAILING ADDRESS FAX# <br /> 215 West Dakota Avenue (559)348-2190 <br /> CITY Clovis STATE CA ZIP 93612 <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 /> 1 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 FEDE It . <br /> APPLICANT'S SIGNATURE: /per r i DATE: y�/�1� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I ATNAGERL3 OTNERA(4HORUYI)AGENT I@ (Senior Manager <br /> If APPLICANT 1s not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />