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SR0077232
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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S
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SEVENTH
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22484
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4700 - Waste Tire Program
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SR0077232
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SR0077232
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Last modified
5/14/2020 3:38:13 PM
Creation date
5/14/2020 1:58:46 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4700 - Waste Tire Program
RECORD_ID
SR0077232
PE
4740
FACILITY_NAME
CALIFORNIA'S TIRES MOBILE SERVICE
STREET_NUMBER
22484
Direction
S
STREET_NAME
SEVENTH
STREET_TYPE
ST
City
TRACY
Zip
95304
APN
25005025
ENTERED_DATE
4/17/2017 12:00:00 AM
SITE_LOCATION
22484 S SEVENTH ST
P_LOCATION
99
P_DISTRICT
005
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 REQUEST# <br /> 5f-00 :- <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS Zak <br /> Street Number Direction Street Name Cit 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 /> PHONE#2 Ex-r. BOS DISTRICT LOCATION CODE <br /> ( ) G U <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 theB1LLINGPARTY 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: �� n �i� l tklZ' <br /> COMMENTS: c„/Ul(t 1'Cij.li��gTCGI t �ro v`� S�pppG't C. <br /> Q` l.C�/,� rj���,�.t��f nr_� +NNO��I.L 5t✓�/b(.L�V� S !-- iv � ""�Al,'�` � �1w-c, w� <br /> ACCEPTED BY: EMPLOYEE#: O��w DATE: <br /> ASSIGNED TO: x r0 EMPLOYEE M O DATE: L V� <br /> Date Service Completed (i ready completed): SERVICE CODE: PIE: L11 Lo <br /> Fee Amount: Amount Paid Q' 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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