Laserfiche WebLink
EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR CHECK if BILLING ADDRESS† <br />FACILITY NAME <br />SITE ADDRESS <br />Street Number <br /> <br />Direction <br /> <br />Street Name City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br /> <br />Street Name <br />CITY STATE ZIP <br />PHONE #1 <br /> ( ) <br />EXT. APN # LAND USE APPLICATION # <br />PHONE #2 <br /> ( ) <br />EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS† <br />BUSINESS NAME PHONE # <br /> ( ) <br />EXT. <br />HOME or MAILING ADDRESS FAX # <br /> ( ) <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENTBILLING 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 />AAPPPPLLIICCAANNTT’’SS SSIIGGNNAATTUURREE:____________________________________________ DATE:___________________________ <br />PROPERTY / BUSINESS OWNER † 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 INFORMATIONAUTHORIZATION 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. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: P / E: <br />Fee Amount: Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br /> <br />Sinclair Ave.95215 <br />173-250-21 <br />1914 <br />813-1184 <br />Silver Almond Ln. <br />Sacramento CA 95834 <br />S. <br />1833 <br />Noelle Ilayan x <br />Ilayan Property <br />Stockton <br />Abby Racco <br />Live Oak GeoEnvironmental <br />407 W. Oak St. <br />Lodi CA 95240 <br />209 369-0375 <br />Review Surface & Subsurface Contamination Report <br />925