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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> '6000 `Mk oo <br /> OWNER / OPERATOR <br /> Steve KIUdt CHECK If BILLING ADDRESS <br /> FACILITY NAME Kludt And Sons <br /> SITE ADDRESS 1126 E Pine Street Lodi 95241 <br /> Street Number Dlrectlon 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- ) 466- 8969 <br /> PHONE #2 EXr• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECK if BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE # EXT• <br /> 209 461 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr ( 209 ) 461 -6342 <br /> CITY Stockton 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 or <br /> activity will be billed to me or my business as identified on this form . <br /> 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. Ll <br /> ( l lAPPLICANT' S SIGNATURE : DATE : ✓ ( ` / <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT ® Office Assistant <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 prop Igcated at the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or enviro yQ� ssment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at t P ��rovided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : �{`1 COUNll <br /> CIU L <br /> SP .TN pEPPR�MENT <br /> H <br /> ACCEPTED BY : t EMPLOYEE #: I DATE: q1 <br /> ASSIGNED TO : Z '] „ EMPLOYEE #: I DATE: y <br /> Date Service Completed ( if already completed) : SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid ( � S (e C� Payment Date Z Z t l <br /> Payment Type vsck . Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />