Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR Patricia Van Groningen CHECK if BILLING ADDRESS <br /> FACIUTYNAME Van Groningen Property <br /> SITE ADORES . 12151 S. Jack Tone Rd. Manteca 95336 <br /> Street Number I Direction I Streeti ZI <br /> HOME or MAILING ADDRESS (If Different from Site Address) 15176 Jack Tone Rd. <br /> Street Number Street me <br /> CITY Manteca STATE CA ZIP 95336 <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> (209 ) 982-4349 201-140-02 <br /> PHONE#2T BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# W. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAx# <br /> 407 W. Oak St. (209)369-0377 <br /> Cm 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 he billed to me or my business as identified on this form. <br /> I also certify that t 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&6 e<❑ M ❑ DATE: <br /> ,�,�7�� <br /> PROPERTY/BUSINESS OWNEROPERATOR/ ANAGEROTHER AUTHORIZED AGENT W Gaiir-y ' A+ ` <br /> If APPLICANT is not the B/LLING 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 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 <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: �� EMPLOYEE M DATE: (D' Z-Jp•(� <br /> Date Service Completed (Kalready completed): SERVICE CODE: 31� PIE: <br /> Fee Amount: L O' Amount Paid a CSU d J Payment Date G 6 f <br /> Payment Type Invoice# Check# ('3 $ ived By: <br /> EHD 48-02-025 RECEIAMORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> JUN 2 6 20:o <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br />