Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # nSERVICE REQUEST # <br /> County Hospital F11 OC 009: C� � Q Dog 1; <br /> OWNER / OPERATOR <br /> San Joaquin General Hospital/ Jesse Escotto CHECK if BILLING ADDRESS El <br /> FACILITY NAME San Joaquin General Hosptial <br /> SITE ADDRESS W Hospital Wy French Camp 95231 <br /> 500 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 E7 APN # LAND USE APPLICATION # <br /> ( 209, 468-7063 <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Ann Marie or Joe CHECK if BILLING ADDRESS <br /> BUSINESS NAME Ba Ie Enterprises , Inc PHONE # Exr. <br /> 9 y p 204 367-4800 <br /> HOME or MAILING ADDRESS FAX # <br /> 2370 Maggio Cir #4 ( 209) 367-5424 <br /> CITY Lodi STATE CA 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 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 : CLDATE : �l�,TJ �-mss <br /> PROPERTY / BUSINESS OWNER ❑ OPERATO MANAGER 171OTHER At AGENT E) Contractor/Designated Operator <br /> If APPLICANT Is not the BILLING PARTY, proof of authorization to Sigh is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property locate Tsite address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessor <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It is available and at the same time it is pf BLVD <br /> my representative. SEP )2 <br /> p ,, ` <br /> TYPE OF SERVICE REQUESTED : }f}g}�} l d g L4 ST P,-e, rC it <br /> COMMENTSJOAQUINSAN Co NTY <br /> : ENVIRONMENT <br /> During the last monitor certification it was determined this site needs to install a leak detector. d HEALTH DEPARTM NT <br /> RLP a4 c (Yt orw- Gil a1 4'M <br /> ACCEPTED BY: ��/ � EMPLOYEE #: DATE: <br /> ASSIGNED TO : � n ��/�Ca !`� EMPLOYEE #: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: �O � O Amount Paid s Payment Date / <br /> Payment Type Invoice # Check # 3 y YSwtq r Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />