Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVII110E REQUEST# <br /> Spo -�7 <br /> eq <br /> OWNER/OPERATOR <br /> Nicholas Kimoto CHECK if BILLING ADDRESS <br /> FACILITY DAME Kimoto Property <br /> SITE ADDRESS 2721S. Pock Ln. Stockton 95205 <br /> Street Number Direction I Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) same <br /> Street NumberT Street Name <br /> CITY STATE ZIP <br /> PHONE#'1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 406-6709 179-120-03 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAx# <br /> 407 W. Oak St. <br /> ( ) <br /> CITY Lodi STATE CA Z'P 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,Standards, STA and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE; <br /> CfROPERT /BUSINESS OWNE'3tj OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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. w <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Nitrate Loading Study A <br /> COMMENTS: % <br /> � o <br /> �Th'OON'I1FcOU <br /> ACCEPTED BY: cnA EMPLOYEE MC0 DATE: 2 i <br /> ASSIGNED TO: EMPLOYEE M as DATE: Z <br /> Date Service Completed (if already completed): SERVICE CODE: S �j? PIE: <br /> Fee Amount: Amount Paid Payment Date 2 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 I �CIP SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />