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SR0077105
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4700 - Waste Tire Program
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SR0077105
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SR0077105
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Last modified
5/14/2020 2:49:17 PM
Creation date
5/14/2020 1:57:05 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4700 - Waste Tire Program
RECORD_ID
SR0077105
PE
4740
FACILITY_NAME
RICHARD TEICHERIA 1 TIME CLEAN UP
STREET_NUMBER
13742
Direction
S
STREET_NAME
CARROLTON
STREET_TYPE
RD
City
ESCALON
Zip
95320
APN
20511001
ENTERED_DATE
3/30/2017 12:00:00 AM
SITE_LOCATION
13742 S CARROLTON RD
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
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CField
Tags
EHD - Public
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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REDJJEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME n,A1,61W4 -r�A C)411�`C, <br /> SITE ADDRESS 13'1 Lt 2 C ✓O 1+9,, �c, �SC�-(0 ex <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> U 01 <br /> PHONE#2 EXT BOS DIST I LOC O CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLINGPA-R 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: to,-JO-4+C e S, ; �.v�► /� <br /> COMMENTS: 1lKe. ��E�J,aGB] ✓ ^,'rv.rC. 4-o w�P•u-r oc .+�4✓V3�G til -v�PZ Dr" <br /> t, Q c ✓d �1'c i .�n fes,`: S Ke c P 4"� cCF •-f►w.-e- <br /> ACCEPTED BY: r b EMPLOYEE#: �u A DATE: 3130 /1 -1 <br /> ASSIGNED TO: tEMPLOYEE#: O 'Z'( DATE:t t\ 3y / <br /> Date Service Completed (if ready completed): SERVICE CODE: P I E: 0 <br /> Fee Amount: Amount Paid Or Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />
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