Laserfiche WebLink
SAN JOAQUIN COUNT . -.vVIRONMENTALHEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2a) q911 32z� <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> Boll Koch <br /> FACILITY NAME <br /> Siegfried <br /> SITE ADDRESS a (oS Thornton & Thornton <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4045 Coronado Avenue <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Stockton CA 95204 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( ) <br /> 1001-150-M&56 U.uaesigr d �f G <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ► <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> Nancy Rosulek <br /> BUSINESS NAME PHONE# ExT. <br /> Npal 0- Anderson and Associates, Inc- ( 209)367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 2 Industrial W (2 ) -422 _ <br /> CITY Lodi STATE CA ZIP 95240 <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 /> I also certify that I have prepared this application and thatthe wo to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL la <br /> APPLICANT'S SIGNATURE: ��d � DATE: <br /> ALT / LL <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR t:MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPL/CANT is not the BILLING PARTY,proof 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:Soil Suitability Study Review ,� <br /> COMMENTS: <br /> C OCT - 4 2006 <br /> SAN JOAQUIN COUNTY <br /> Sm ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: 2L2 EMPLOYEE#: 7379 DATE: C �� <br /> ASSIGNED TO: G EMPLOYEE#: 3 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: L Z P I E: ��D <br /> Fee Amount: 7�� Amount Paid � Payment Date 1 D p <br /> Payment Type Invoice# Check# �,5 3 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />