Laserfiche WebLink
SAN JOAQUIVIOUNTY ENVIRONMENTAL HEALT10 <br /> EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SlF, VIC QUEST# <br /> Hospital s O� 3 <br /> OWNER/OPERATOR <br /> Kaiser Foundation-Manteca CHECK If BILLING ADDRESS <br /> FACILITY NAME Kaiser Permanente <br /> SITE ADDRESS 1777 W Yosemite Ave Manteca 95337 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209)825-3651 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Mike Ellis CHECK If BILLING ADDRESS <br /> BUSINESS NAME Belshire Environmental Services, Inc. PHONE# EXT. <br /> ( 675-7233 <br /> HOME or MAILING ADDRESS FAX# <br /> 25971 Towne Centre Dr. ( 949) 460-5200 <br /> CITY Foothill Ranch STATE CA ZIP 92610 <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 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: P I Llt ZMd• DATE: 10/29/2018 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGENT[X Project Manager <br /> If APPLICANT 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 th ,a time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: *® <br /> COMMENTS: h ✓O O <br /> �cco'�F,y o <br /> tir <br /> ACCEPTED BY: � R -mac EMPLOYEE#: � ) DATE: 1! 1�` <br /> ASSIGNED TO: Z j N C_ 1-.�� \r EMPLOYEE#: 00 r% fi DATE: J1 I <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: GJ� Amount Pai �L�� D� Payment Date Sf S <br /> Payment Type Invoice# Check# 773_'�_40 Received By: - <br /> EHD 48-02-025 VVI` �� G�l,6 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />