Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Municipal "/ �/� �7 +� S <br /> OWNER/OPERATOR -f <br /> City of Lodi CHECK If BILLING ADDRESSO <br /> FACILITYNAME City of Lodi Municipal Service Center <br /> SITE ADDRESS 1331 S Ham Lane <br /> Lodi T95241 <br /> Street Number Direction Street Name city Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address)S <br /> (q Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 333-6740 031-010-50 <br /> PHONE#Z ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR -n _� <br /> /� oRi CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> /ter► �i�DiZl'� 0/L /.11G. 209 ) ,3669"6175 <br /> HOME or MAILING ADDRESS .I FAX# <br /> P OX .� `� ' ( 209) <br /> CITY / O/9 / STATE CA ZIP / <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,Standardv- STA w <br /> APPLICANT'S SIGNATURE: / DATE: ®,y �L <br /> PROPERTY/BUSINESS OWNER❑ O BATOR/ WAGER 1:1 OTHER AUTHORIZED AGENT® w/V <br /> If APPLICANT is not the B LUNG PARTY proof of thoriZation 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 environmentaUsite 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: <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVE <br /> MAR 18 2 11 <br /> SAN JOAQUIN CC UALMY <br /> ACCEPTED BY: (I^` EMPLOYEE#: e312 <br /> DATE: J fh 5EPARTAIENT <br /> ASSIGNED TO: o EMPLOYEE#: I '-f 2,2- <br /> 2- DATE <br /> Date Service Completed (if already completed): SERVICE CODE: 6 -P/E: <br /> l <br /> Fee Amount: U Amount Paid Q U Payment Date 1 I <br /> Payment Type �j Invoice# Check# 39 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />