Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property PAGILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> EkLuwr AD <br /> Hd1r15Cq Q L.LC. `` CHECK If <br /> FAciuTr NAME __t pLuca&r CpP�iy WA <br /> SITE ADDRESS 1"^26955S Hansen Road Tracy 95304 <br /> west Number Na C <br /> HOME or MAILING ADDRESS (N Different from Site Acidness) <br /> P,o.^pOX l Street Number street ICrrrHI <br /> p <br /> CITY TrSTATE C,,, zip (?S-3,78 <br /> PHONE#t APN# LAND USE APPLICATION# <br /> fao9) 83aL-480- 209-110-09 <br /> NONE 92 Exr. SOS DISTRICT Cocc_ <br /> (ao9) tBa-y8o3 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS O <br /> Nancy R Kramer <br /> BUSINESS NAME PHONE# Elcr' <br /> HOME Or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209)369-4228 <br /> CITU Lorfi STATE CA ZIP <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 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 /> 1 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: 4' DATE: S///07 <br /> orI <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> if APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 t0 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 SERVICEREQUEsTED: Soil Suitability <br /> _Study/ Nitrate Loading Study <br /> COMMENTS: �3 rJQ � .�., X27,...,.i�9f�iv � JUL 1 8 2007 <br /> SANO COUNTY <br /> l"llY <br /> ENVIRONMENTAL ENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED S'/: EMPLOYEE#: 3/ Da:e: <br /> ASSIGNED TO: <br /> Date Service Completed (it already completed): SERVICE CODE: P;E, <br /> Fee Amount: Amount Paid IT, S'. L, •, Payment Date `7 3 <br /> Payment Type i, Invoice# Check <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 65-02 <br />