Laserfiche WebLink
( <br />FACILITY ID # <br />£ <br />L-? <br />Faciuty Name <br />Site Address ^2-^0 <br />Zip Coda <br />City ji <br />Ext. <br />Ext.BOS District <br />Requestor Jerame Lennen <br />Business Name ExtLennen Commercial Builders,Inc.451-0350 <br />451-1074 <br />Zip 95203CityState CAStockton <br />be performed will be done in accordance with all San Joaquin'Ol <br />Type of Service Requested: <br />Comments:Plan review <br />5-2-24Vidal Pedraza Employee #: 6213 Date:Accepted By: <br />5-2-249838Francisco Ruiz Employee #:Date:Assigned to: <br />1601523Date Service Completed (if already completed):Service Code: <br />Payment DateFee Amount: <br />Payment Type Invoice # <br />Payment 180777436 <br />SR FORM (Golden Rod) <br />I also certify that I have prepared this application and that-N <br />County Ordinance Codes. Standards. State and^Et^RAi la' <br />EHD 48-02-025 <br />03/22/23 <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <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 activity <br />will be billed to me or my business as identified on this form. <br />Street Number Direction <br />Home or Mailing Address (If Different from Site Address) <br />Phone# <br />(209) <br />Fax# <br />EMA1ijeraineglennenbuilders. com <br />sy'i/zo <br />Check if Billing Address D <br />Type of Business or Property <br />Owner / Operator . \ n- <br />______iM/A.vrVCev "TXvevvi Ueju <br />SERVICE REQUEST# <br />fiQx2>88Q>((g> <br />Check if Billing AddressJ^J <br />APN# <br />04-3-036 -11? <br />Email <br />yu c I'- p IX) _ <br />CONTRACTOR / SERVICE REQUESTOR <br />Land Use Application # <br />^LT-o^-o^ <br />Location Code <br />City <br />_______________ Street Name <br />ZipSVocLAoia <br />Phone #1 <br />Phone #2 <br />( ) <br />^36Street Number <br />P/E: <br />-A -!Received By: <br />Home or Mailing Address <br />501 N. Baker St. <br />APPLICANT’S SIGNATURE: DATE:. <br />Property / Business Owner ^Operator / Manager □ Other Authorized Agent □ <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 above site <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment informaLon to the <br />San Joaquin County Environmental Health Department as soon as it is available and at the same time it is provided <br />representative. <br />Amount Paid^yg^ ^ <br />| check# 77^3^