Laserfiche WebLink
SAN JOAQUP "70UNTY ENVIRONMENTAL HEALTY- 1)EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME Manteca Inn <br />SITE ADDRESS 150 <br />Street Number Direction <br />Northwoods Dr <br />Street Name <br />Manteca <br />City <br />95336 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 Err. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 En. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR Tim Hempleman CHECK if BILLING ADDRESS jo <br />BUSINESS NAME Hempleman's Pool Cures PHONE # <br />( 209 ) 614-6385 <br />Err. <br />HOME or MAILING ADDRESS 11749 Sawyer Ave FAX # <br />( 209 ) 847-3305 <br />Crix Oakdale STATE CA ZIP 95361 <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 <br />APPLICANT'S SIGNATURE: <br /> <br />PROPE TV / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT K1 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br /> <br />Contractor <br /> <br />Title <br /> <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />aKiveSiic address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />infonnaTIop to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />prcrcidOtotime or my representative. <br />TypesiF Seli4ItE REQUESTED: VGB Compliance <br />,. 1../14 <br />Comments: , . .. „ , <br />r 1E00E, Yr <br />VED <br />144Y 2 6 2011 sAN,0AQ , ,_,Ez.1,3p,,,N71, <br />DEpAuzilig-NT <br />ACCEPTED BY: e-, -- ". ...., t EMPLOYEE #: (c., -zt 5 DATE: c--. IA" _ 1( <br />ASSIGNED TO: r dArck.7--es.... EMPLOYEE #: t„-?__{ 3 DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 3- ).._ 2..— P/E: 4(002 <br />Fee Amount: -f Amount Paid 4 ut Payment Date 1 2_ Li II <br />Payment Type Invoice # Check # Received By: WC,._ <br />DATE: 12-15-2010