Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SK <br /> OWNER/OPERATOR <br /> Dennis Borba CHECK If BILLING ADDRESS <br /> FACILITY NAME Borba Property <br /> SITE ADDRESS 24011 1 E. Dodds Rd. Q53w <br /> Street Number DireMion Street Name Escalon Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) P.O. Box 192 <br /> Street Number Street Name <br /> CITY Escalon STATE CA ZIP 95320 <br /> PHONE#1 EXT. APN# LAND USE APPu TION# <br /> (209 ) 531-3494 207-150-06 - 4(Q0'� <br /> PHONE#2 ExT. BOS DISTRICT LOCA ION CODE <br /> ( ) DO "1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex T. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAx# <br /> 407 W. Oak St. <br /> ( ) <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 <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 JOAQLTN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY t BUSINESS OWNER❑ OPERATOR t MA NAGER ❑ OTHER AUTHORIZED AGENT e c avSV 1.I Anj"T- <br /> IfAPPL1C'ANT is not the Biii-iNG PARTY,proof of authorization to sign is required Tete <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: Review Surface & Subsurface Contamination Report � 'per <br /> COMMENTS: PAYMENT <br /> V' I 3� 7 •� µ,y> RECEIVEDD <br /> j 1 W4- v VNkv 'lst JUL 17 2014 <br /> t" SAN JOAQUIN COUNTY <br /> ACCEPTED BY: ,�I /�J. 1� EMPLOYEE#: H <br /> ASSIGNED TO: T EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 7/ P I E: 6 Q <br /> Fee AmountZ�0 Amount Paid 'ZV0 ®fly Payment Date l 7 <br /> Payment Type Invoice# Check# Received y: <br /> E H D 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />