SR0083996_SSCRPT - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK BILLING ADDRESS SERVICE REQUEST # If BUSINESS NAME OWNER /OPERATOR EXT. James & Angela La Vel le / John & AnnaMarie Lara CHECK if BILLING ADDRESS FACILITY NAME La Velle / Lara Property 369-0375 STA?�1ESA2619 32705 S. Koster Rd. Tracy 407 W. Oak St. 95304 Street Number Direction Street Name STATE CA Cit Zio Code HOME or MAILING ADDRESS (If Different from Site Address) 475W. Blewett Rd. c/o Carl Navarra Street Number Street Name CITY STATE ZIP Tracy CA 95304 PHONE #1 EXT_ APN # LAND USE APPLICATION # ( 209) 471-5757 255-100-26, -35, & -36 PHONE #2 EXT. BOS DISTRICT LOCATgION CODE CONTRACTOR / SERVICE REOUESTOR REQUESTOR CHECK BILLING ADDRESS Abby Racco If BUSINESS NAME PHONE # EXT. Live Oak GeoEnvironmental 209 369-0375 HOME or MAILING ADDRESS FAx # 407 W. Oak St. ( ) CITY Lodi STATE CA ZIP 95240 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: IOMIC4 kE DATE: -7 - 2 -Ce - z 1 PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® C'. 0 NfV (--TAN T If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and Atime it is provided to me or my representative. ) PP;: MQvi- TYPE OF SERVICE REQUESTED: COMMENTS: Review Surface & Subsurface Contamination Report SqN ✓ - c p 2021 4/4wQuw ' TI ! NT ACCEPTED BY: EMPLOYEE#: DATE: Vd6l,;% ASSIGNED TO: Qj�9C I.� s EMPLOYEE #: DATE: Z� Date Service Completed (if already Completed): SERVICE CODE: �a 3 P I E: a v S Fee Amount: Amount Paid t Payment Date 2CQ D Payment Type Invoice # Check # Received By: 1.,xJ EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)