Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Hotel NW S200g0 2,(.0 <br /> OWNER/OPERATOR <br /> Louise Avenue Partners; Andy Kotecha CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> TRU by Hilton, Lathrop <br /> SITE ADDRESS 161 1 E. Louise Ave. Lathrop 95330 <br /> Street Number Dlrectlon Street Name city ZIP Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 103 E. Louise Ave. <br /> Street Number Street Name <br /> CRY Lathrop STATE CA ZIP 95330 <br /> PHONE#1 619 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) -&"-1073 196-270-23 <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> TBD CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ext. <br /> HOME Or MAILING ADDRESS FAz# <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 applicatio and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT F oERAL laws. <br /> APPLICANT'S SIGNATU�yRI,E: DATE: <br /> PROPERTY/BUSINESS OWNERL OPERAT R/ AGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/cAN'Tisnot the BILLING PAR T'Yproof ofauthorization tosign isrequired 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the(lam@[Ime it is <br /> provided to me or my representative. a N. �Ic <br /> TYPE OF SERVICE REQUESTED: PionClheGit� C�`I <br /> COMMENTS: <br /> Pl(qns mi(Pd S4NJ04Co <br /> y QF qs NT <br /> ACCEPTED BY: I�, O EMPLOYEE#: DATE: 7 I0 <br /> ASSIGNED TO: /1 EMPLOYEE M DATE: 7 O✓ ' <br /> Date Service Comple ed (If already completed): SERVICE CODE: j27J- P//E: I <br /> Fee Amount: I L15ze Amount Pai L15-6 Od I <br /> Payment Date /3 <br /> Payment Type GL— Invoice# Check# Rec ive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />