Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Abby Racco <br />OWNER/ OPERATOR <br />Carole Pinnell <br />CHECK if BILLING ADDRESS <br />FACILITY NAME Pinnell Property <br />SITE ADDRESS 8888 <br />W <br />Pine St. <br />Thornton <br />95686 <br />Street Number <br />Direction <br />Z'P 95240 <br />Street Name <br />Ci <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />5764 <br />1 W. Kingdon Rd. <br />Street Number <br />Street Name <br />CITY Lodi <br />STATE CA ZIP 95242 <br />PHnNF 01 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 209) 400-0360 <br />001-200-20 <br />PHONE #2 EXT. <br />BOS DISTRICT `� <br />LOCATION CODE <br />( ) <br />PC <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />Abby Racco <br />BUSINESS NAME <br />Live Oak Geo Environmental <br />PHONE # <br />209 <br />EXT. <br />369-0375 <br />HOME or MAILING ADDRESS <br />FAx # <br />407 W. Oak St. <br />( ) <br />CITY Lodi <br />STATE CA <br />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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: 1 r DATE: B, —7Z, 2-i <br />PROPERTY/ BUSINESS OWNER® OPERATOR NAGER 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 tip& <br />provided to me or my representative. �rr0.r-„ it <br />TYPE OF SERVICE REQUESTED: Review Soil Suitability / Nitrate Loading Study <br />COMMENTS: <br />SAN JOAQUIN COUN <br />ENVIRONMENTAL <br />HEALTH DEPARTME <br />ACCEPTED BY: �'�� �� �� EMPLOYEE #: DATE: 7 7f ,2,7 <br />ASSIGNED TO: Q J A EMPLOYEE #: DATE: -7171,W) <br />Date Service Completed (if already completed): SERVICE CODE: 5' 3 P I E: a 603 <br />Fee Amount: 409 Amount Paid Payment Date Y/2 --f) I <br />Payment Type % All I Invoice # Check # /, / q /'�) I Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />