Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK if BILLING ADDRESS <br />SERVICE REQUEST # <br />BUSINESS NAME <br />dol q <br />OWNER/ OPERATOR <br />EXT. <br />Ranjit Gill & Ravinder Singh Dhilon <br />CHECK if BILLING ADDRESSX❑ <br />FACILITY NAME Proposed Truck Parking Terminal <br />369-0375 <br />SITE ADDRESS 150W. <br />Frewert Rd. <br />I <br />Lathrop <br />95330 <br />Street Number <br />Direction <br />Street Name <br />STATE CA <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 403 <br />Riley <br />Ct. <br />Street Number <br />Street Name <br />CITY Tracy <br />STATE CA ZIP 95377 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 209) 640-9078 <br />191-230-12 & -14 <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />Abby Racco <br />BUSINESS NAME <br />PHONE # <br />EXT. <br />Live Oak Geo Environmental <br />209 <br />369-0375 <br />HOME or MAILING ADDRESS <br />FAX # <br />407 W. Oak St. <br />( <br />) <br />CITY Lodi <br />STATE CA <br />ZIP 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 EDERAL laws. p <br />APPLICANT'S SIGNATURE: / DATE: -/ ' Z I <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT C 0 NS 1ll.Tft N'i <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. <br />TYPE OF SERVICE REQUESTED: Review Soil Suitability / Nitrate Loading StudyR T <br />COMMENTS:'�� � �2O2i <br />S EN�ORQUIN CO <br />HF -ACTH EIV rAL ' <br />ACCEPTED BY: --� Z:1L EMPLOYEE DATE: <br />ASSIGNED TO:C EMPLOYEE M DATE: <br />1 <br />Date Service Completed (if already completed): SERVICE CODE: P / E. a 60.7 <br />41 <br />Fee Amount: 4 (C'(D Amount P � D8, U�) Payment Date � 1 Z <br />Payment TypeC /� Invoice # Check # I 9 4�' Rece' ed By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />