Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S�OO� � lS� <br /> OWNER I OPERATOR Peter Lenz <br /> CHECK IT BILLING ADDRESS <br /> FACILITY NAME <br /> SHEADDRESS 1648 N Shaw Rd. Stockton 95215 <br /> Street Number Direction Street Name city Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6507 Pacific Ave. Suite #134 <br /> Street Number I Street Name <br /> CITY Stockton STATE CA ZIP 95207 <br /> PHONE#1 EXT' APN# LAND USE APPLICATION <br /> ( ) 143-260-15, 16 : " ins <br /> PHONE#2 En. BOB DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Louie Mendez <br /> CHECK If BILLING ADDRESS <br /> BPHONE# E'r. <br /> BUSINESS NAME <br /> Dillon & Murphy 209 334-6613 <br /> HOME or MAILING ADDRESS P.O. Box 2180 209 ) 334-0723 <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 <br /> or activity will be billed to me or my business as identified o his form. <br /> 1 also certify that I have prepared this application and that a ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDE <br /> APPLICANT'S SIGNATURE: DATE5 <br /> �:I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAG t [3 OTHER AUTHORIZED AGENTIry I Staff <br /> It <br /> /fAPPLfCANT is not the BILL/NG PARTY pr f of authorization 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 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: <br /> COMMENTS: 3/ / I� /4P,+J Q <br /> �® <br /> P:FPOT7(12Er//62J� �G �1 H F JOAoTUNco lI <br /> /Y/_ F ez 5�6- ' O / M�� �<Tli UEPgRTTq N'Y <br /> ACCEPTED BY: /.1 ( '1 EMPLOYEE#: DATE: LfC I.7 <br /> ASSIGNED TO: ✓L EJ(� EMPLOYEE#: DATE: J5 I-7 <br /> Date Service Completed (if already completed): SERVICE CODE: J6 y23 PIE: z(?D-3 <br /> Fee Amount: 'y7 V Amount Paid 27g,0 D Payment Date �7 in <br /> Payment Type Invoice# Check# J� � l� Recei ed By: <br /> EHD 48-02-025 <br /> SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />