Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# §ERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Sergio Martinez CHECK If BILLINGADDRESSE] <br /> FACILITY NAME <br /> SITE ADDRESS 3928 E. <br /> Miner Avenue Stockton 95202 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 24242 Street Number Partridge treetLaNe e <br /> ame <br /> CITY STATE ZIP 95220 <br /> Acampo CA <br /> PHONE#t EXT. A # LAND USE APPLICATION# <br /> (209 ) 993-7010 13-350-10 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Joe Murphy CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Dillon & Murphy 20 334-6613 117 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 2180 ( ) <br /> CITY Lodi STATE CA ZIP 95241 <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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, Standargs, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �1/L, �'� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not th'e�ALLING PARTY, proof of authorization to sign IS required Title <br /> AUTHORIZATION TO RELEASE II�IF.�RMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided t0 me Or <br /> my representative. Ad to. <br /> TYPE OF SERVICE REQUESTED: �tl <br /> COMMENTS: ®o <br /> ��a �?9 ?019 <br /> N FNV/ROAI;COU �, <br /> F'4CTy OE� N <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if air ady completed): SERVICE CODE: 5 P I E: D <br /> Fee Amount: S Amount Paid 3d , Payment Date-- <br /> Payment <br /> at Payment Type Invoice# Check# /S Received By: _ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />