Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> GDF `,(<� a)F05 30 <br /> OWNER / OPERATOR <br /> BG Group - Hardeep Gill CHECK If BILLING ADDRESS <br /> FACILITY NAME FastLane Central Valley <br /> SITE ADDRESS 116 Roth Road Lathrop 95330 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # <br /> ( 7071 431 -351 1 Iq 6 - ' �o <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Janelle Dockham CHECKif BILLING ADDRESS El <br /> BUSINESS NAME PHONE # E)cr' <br /> Nwestco , LLC 661 <br /> HOME or MAILING ADDRESS FAX # <br /> 2209 Zeus Court ( 661 ) 587-9758 <br /> CITY Bakersfield STATE CA ZIP 93308 <br /> BILLING ACKNOWLEDGEMENT : 1 , 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 Or <br /> activity will be billed to me or my business as identified on this form . <br /> 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 : 01a7�eC�er, DATE : 05/24/2022 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Permit Clerk <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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site asses ent information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time it is I tQ ne Or <br /> my representative . pr, t At <br /> �` <br /> TYPE OF SERVICE REQUESTED : ( �( S+ � a7-� L <br /> COMMENTS : � � Sq 0 J Z�z2 <br /> N JO'4QUIU <br /> NEgLCOO <br /> TH DepgR ML T <br /> NT <br /> ACCEPTED BY: ( ,�jj /+ L <br /> EMPLOYEE DATE : 2 2aL <br /> ASSIGNED TO : V EMPLOYEE #: DATE: L`J/2 <br /> Date Service Completed (if already completed) : - ` SERVICE CODE: + - � P I E : 2C� ' <br /> Fee Amount : 47t) Amount Paid �� v Payment Date ZZ <br /> Payment Type VZ 1` 5Q Invoice # I Check # 1 f z3 S�2- D Received By: <br /> 1 - f l`fgS36 <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />