Laserfiche WebLink
SAN JOAQLOCOUNTY ENVIRONMENTAL HEALT,EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />County Owned Facility <br />FACILITY ID # <br />SERVICE REQUEST # <br />2 (0 0, <br />OWNER / OPERATOR <br />S. J. County Public Works (Dan McCann - Fleet Manager) CHECK if BILLING ADDRESS <br />FACILITY NAME <br />Downtown Garaize <br />CHECK if BILLING ADDRES <br />BMg�ey�nterprises, Inc. <br />SITE ADDRESS <br />121 Street Number <br />DlreonFSanJoaquin <br />StraMe <br />St?.ckton <br />ACCEPTED BY: GL t L C I �' <br />95202 <br />zlD Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />(209) <br />CITY <br />STATE zip <br />STATE CA <br />PHONE #1 EXT. <br />APN # <br />Fee Amount: Cl �s <br />LAND USE APPLICATION # <br />Payment Date (p — <br />PHONE #2 EXT. <br />Invoice # <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />a'F -1J-j F- (T pp: P' �i qT <br />COMMENTS: <br />Joseph Bagley <br />�r C� � %jo�� 'Foe- <br />CHECK if BILLING ADDRES <br />BMg�ey�nterprises, Inc. <br />PHQI�E�i <br />367-4800 Exr. <br />HOME or MAILING ADDRESS <br />ACCEPTED BY: GL t L C I �' <br />FALX## <br />EMPLOYEE #:C �-Lr <br />2370 Maggio Cir. #4 <br />ASSIGNED TO: ' rA -c�&S U J <br />(209) <br />367-5424 <br />CITY Lodi <br />STATE CA <br />ZIP 95240 <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, Standar T and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: Ow" L;) 7 /;P1 o'4' <br />tl VC <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER OTHER AUTHORIZED AGENT El ontractor <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 the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: LAS <br />a'F -1J-j F- (T pp: P' �i qT <br />COMMENTS: <br />�r C� � %jo�� 'Foe- <br />kjv3Oe.�4- Til 2,15 oot-� <br />2 � <br />iUN <br />�� ��� b (� (DSJOAQUIN COUNN <br />SA ENVIRO APARTMENT <br />EpLTH D <br />ACCEPTED BY: GL t L C I �' <br />EMPLOYEE #:C �-Lr <br />DATE: (o t.277 t C1,,-- <br />ASSIGNED TO: ' rA -c�&S U J <br />EMPLOYEE #: F3-7 3 <br />DATE: b L-7 &C <br />Date Service Completed (if already completed): <br />SERVICE CODE: t 1 r <br />P / E: -�3 of <br />Fee Amount: Cl �s <br />Amount Paid '5 J-_7 41 a D <br />Payment Date (p — <br />Payment Type <br />Invoice # <br />Check #�,D b o1g <br />Received By: 7� <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden R&J< <br />