Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH.PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Former UST location <br />FACILITY ID # SERVICE REQUEST # <br />OWNER! OPERATOR <br />CHECK if Ray Farmer Enterprises Inc. BILLING ADDRESS <br />FACILITY NAME Former Toyota Town <br />SITE ADDRESS <br />610 Street Number <br />North DNireOct <br />r n Direction <br />Hunter Street <br />Street Name <br />Stockton City <br />95202 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 2606 <br />Street Number <br />Sheridan Way <br />Street Name <br />CiTy STATE ZIP <br />Stockton CA 95207 <br />PHONE #1 Exr. <br />( ) <br />AP N # LA SEND U PPLICATION # <br />139-060-33 <br />PHONE #2 EXT <br />( ) <br />BOS !STRICT LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />Jeanne Homsey CHECK if BILLING ADDRESS X <br />BUSINESS NAME ATC Group Services LLC <br />PHONE # <br />( 209 <br />EXT. <br />) 579-2221 <br />HOME or MAILING ADDRESS 1117 Lone Palm Avenue, Suite 201B <br />FAX # <br />( 209 )579-2225 <br />CITY Modesto STATE CA ZIP 95351 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned prope or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL I ALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this orm. <br />I also certify that I have prepared this application and that the w k to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL la <br /> <br />DATE: Oct (0 C) <br /> <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OVVNEREI RATOR / MANAGE <br /> <br />OTHER AUTHORIZED AGENT lEr CO4 SC) I-fet 14:T <br /> <br />If APPLICANT is not the BILLING PARTY, pr of of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATI : When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release o any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRON NTAL 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: <br />COMMENTS: <br />/ E, <br />DATE: <br />yp CIE1[1Y2 :7, <br />rJE144•41.1SERVICES <br />ACCEPTED BY: EMPLOYEE #: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: P I E: <br />Fee Amount: Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003