Laserfiche WebLink
SAN JOAQLIIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Restaurant ?) / 0 V-1-1 D <br /> OWNER/OPERATOR <br /> Pacific Bells LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME Taco Bell <br /> SITE ADDRESS 16905 Harlan Road Lathrop 95330 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 111 W 39th Street <br /> Street Number Street Name <br /> CITY Vancouver STATE WA ZIP 98660 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (360 ) 694-7855 198-210-090-000 <br /> PHONE 92 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Craig Gilbert CHECK If BILLING ADDRESS <br /> BUSINESS NAME PM Design Group PHONE <br /> # EXT. <br /> 360 719-1953 <br /> HOME or MAILING ADDRESS FAx# <br /> 19120 SE 34th Street. Suite 115 <br /> ( 360 ) 719-1955 <br /> CITY Vancouver STATE WA ZIP 98683 <br /> BILLING ACKNOWLEDGEMENT: I. the undersigned property or business o-wrier. operator or authorized agent of same. <br /> acknowledge that all site and or project specific F.N%'IRONNII\i.\l Hi.\i III DI h\RI.\II Ni hourlc charges associated �sith this project <br /> or activity\%ill be billed to me or me business as identified un this form. <br /> also certify that I h t%e prepared this application and that the ssork to be performed\sill be done in accordance\\ith all SAN J0rA0I'(5 <br /> C(A IN l Y Urclinun«e Ci)c%.c.J7urti(ur4/ 1.\ F and H:i it.\i. la\\s. <br /> APPLICANT'S SIGNATURE: eel,, D.%rE: 6/177/2019 <br /> PROPFRIN /tit SIN ESS 0%\NER❑ OPER\rOR/\L\\AGt:R ❑ 0IIIERAt rIN)RIZF.D-k(;E\T <br /> /J. I\I is n(,l the B11.L1P.IRI).proof')f authorization to sign is required Tule� <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 an\ and all results. geotechnical data and or environmental site assessment <br /> information to the S\N JO.UH"IN COI'\IN, ENVIRONMI N1.\i HF.V til Di PUtI\HFNI as soon as it is available andwlt the same time it is <br /> provided to me or m\ representative. A <br /> TYPE OF SERVICE REQUESTED: C •r <br /> COMMENTS: UN o <br /> qAl <br /> HS N�ogQ�? o 201,9�<Ty�Fp <br /> MF <br /> ACCEPTED BY: U EMPLOYEE#: DATE: <br /> ASSIGNED TO: ���2 EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: r7,!3 P f E: <br /> Fee Amou T� D Amount P Payment Date <br /> Payment Type Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />