Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Auto Repair � � w <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Jahn Bubica <br /> FACILITY NAME <br /> DBL Rentals Property <br /> SITE ADDRESS / � �� North Sacramento Street <br /> 619aTTl1�2$ lv Lodi 95242 <br /> Street Number Direction Street Name city Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) South Ham Lane Suite C <br /> 701 Street Number Street Name <br /> CITY STATE ZIP <br /> Lodi CA 95242 <br /> PHONE #1 ExT• APN # 041190-210 LAND USE APPLICATION # <br /> ( 209 ) 625-5261 041 -190-220 N/A <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Robert Marty <br /> BUSINESS NAME PHONE # ExT. <br /> Advanced GeoEnvironmental Inc. 209 467-1006 <br /> HOME or MAILING ADDRESS FAX # <br /> 837 Shaw Road ( 209 ) 467- 1118 <br /> CITY Stockton STATE CA ZIP 95215 <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, Standard;P. <br /> n <br /> lAPPLICANT ' S SIGNATURE : DATE : (� 9 ?7y � � I <br /> PROPERTY / BUSINESS OWNER ❑ OPE TOR / MANAGE OTHER AUTHORIZED AGENT ® President <br /> IfAPPLICANT 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 environmentab)V assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at� S t is <br /> ritr <br /> provided to me or my representative . //yy (rjjf <br /> TYPE OF SERVICE REQUESTED : ` .�- / � C f / ! D V V� <br /> COMMENTS : S NI/ *1 O�J <br /> Nr <br /> ACCEPTED BY : �, � '4�7' ��_ , EMPLOYEE #: /! � DATE : / o <br /> ASSIGNED TO : Pe <br /> `� EMPLOYEE # : DATE : <br /> Date Service Completed ( if already completed) : SERVICE CODE : � f f P I E : � <br /> D / <br /> Fee Amount: 0--o Amount Paid v� Payment Date <br /> Payment Type Invoice # Check # 2� / Re ce ed By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />