Laserfiche WebLink
FAN JOAQu OUNTY ENVIRONN-ENTAL HEALTI `:PARTMEC "-'I FAY <br /> SERVICE RxIQUEST ~ <br /> Type of Business or Property FACILITY ID I SERVICE REQUEST# <br /> 9LS <br /> OWNER/OPERATOR Mr. James Thoming CHECK If BILLING ADDRESS® <br /> FACILITY NAME Thoming Parcel <br /> SITE ADDRESS 32350 S. A"^em d 5 f CT:3 Trac FI 95304 <br /> Street Number Direction Street Name Ci L Coda <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 33600 Koster Rd. <br /> Street Number Street Name <br /> CITY Tracy STATE CA ZIP 95376 <br /> PHONE#1 E+T APN# LAND USE APPLICATION# <br /> (209) 835-2792 255-150-08 —Unassigned-- PA -03 ppm) <br /> PHONE#2 Ear. BO$DISTRICT LOCATION CODE <br /> ( ) C <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Err. <br /> Neil O. Anderson 81 Associates Inc. 209 367-3701 �r�1 <br /> HOME or MAILING ADDRESS FAX# �f <br /> CITY <br /> 902 Industrial Way (209 )369-4228 O <br /> 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" work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA and FEDERA awsc <br /> APPLICANT'S SIGNATURE: DATE: ^ S <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT[3 <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 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: �k,Lj-i¢�;E ,.G S L.Z 1.L�A G E G C^nTl!4✓'-(1 N{�'-'�Z U e1J p2 �Oa <br /> COMMENTS: Please review the attached Surface Subsurface Contamination Report. If you fi'W6i1T <br /> questions, please do not hesitate to call. RECEIVED <br /> moo,— y � a r <br /> Yari¢Q Vt�'wPr �•5� 1fvvl33 So ^-' APR 5 2005 <br /> d <br /> Iy ,"^1 SAN JOAQUIN COUNTY <br /> APPROVED BY: rel,L/L,.E t �"'t EMPLOYEE#: C)32 / DATFHE NVI N F N IAL <br /> ENT <br /> ASSIGNED TO: vJ{tV 17q NE_ EMPLOYEE#: 4000 DATE: 4 <br /> SIt`D( <br /> Date Service Completed (if already completed): SERwcE CODE: 3( S P 1 E: „C(I„rp3 <br /> Fee Amount: ftr�(o O p Amount Paid ''/ 949,co Payment Date �. 5 <br /> Payment Type Invoice# Check# Received By: <br /> W�DS'�i° ��"' ! /(3 S 1I1g�24c5 -60w.•, SSU vw tt Fakf. I <br /> '/-REVISED S-5-02 ,�I�_w,^' I ,,/�/"�l--" SERVICE REQUEST FORM <br />