Laserfiche WebLink
SAN JOAQUI?"20UNTY ENVIRONMENTAL HEALTH`mWPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> pits"6va&4 30'a <br /> OWNER i OPERATOR Andrew Rehberg <br /> CHECK If BILLING ADDRESSCI <br /> FACILITY NAME DBA: River Point Landing Marina Resort <br /> SITE ADDRESS Buckley Cove Way Stockton, CA 5219 <br /> Street Number I Direction Street Name cfty ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Same Street Number Street Name <br /> CITY Same STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209)951-4144 Marina <br /> PHONE G EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR f SERVICE REQUESTOR <br /> REQUESTOR Jeff Scott CHECK If BILLING ADDRESS® <br /> BUSINESS NAMEEXT. <br /> P <br /> Fillner Construction, Inc. Re 624-1985 232 <br /> HOME or MAILING ADDRESS FAx 0 <br /> 4470 Yankee Hill Rd., Suite 200 ( 916) 625-0911 <br /> CITY Rocklin STATE CA zlP 95677 <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 ENVIRONMFNTAI,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 /> 1 also certify that I have prepared this application and that the w o be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FED Lia s <br /> APPLICANT'S SIGNATURE: DATE: 02-02-12 <br /> PROPERTY/BUSINESS OWNER❑ OPERA/T01174ANAGER ❑ OTHER AUTHORIZED AGENT Estimator <br /> IfAPPLICANT is not the BILLING PAR7_T 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: U x T A2-E-T--o F t <br /> COMMENTS: RECENED <br /> FEB 4 3 2012 <br /> �AL- <br /> WAL.TH DUAWN99 <br /> ACCEPTED BY: 0 L-L t/E I .4A EMPLOYEE M a 24 DATE: 2- r Z <br /> ASSIGNED TO: 4 A GeAt.0 EMPLOYEE#: 4-41 3 6 DATE: 2—(-t <br /> Date Service Completed (if already completed): SERVICE CODE: I �r I PIE: 3 U P <br /> Fee Amount: -7 5-. t-tj Amount Paid,-$7,,5--'— Payment Date <br /> Payment Type /� Invoice# Check# Received By: <br /> EHD 48-02-025 1 / Gwv Z�r SR FORM(Golden Rod) <br /> REVISED 11/17/2003 1sJ --CA <br />