Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTNIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE PPMIJEST# <br /> (A oo o 5--4- SP d 6 S 6563 <br /> OWNER I OPERATOR French Camp Holding Corp. CHECK if BILLING ADDRESS <br /> FACILITY NAME French Camp Turnpike o/a Pride Truck Sales <br /> SITE ADDRESS 2546 French Camp Turnpike Stockton 95206 <br /> Street Number Direction treet Name Cit Zi Code n <br /> HOME or MAILING ADDRESS (If Different from Site Address) ,A050__ Sfxie Rrt'— �jy tG�Ct•O l� f/� <br /> _ ; 'I Street Number Street Name fft <br /> CITY �' STAVE — / ZIP; _ <br /> PHONE#1 ExT• APN# 165-261-250-000 and LAND USE APPLICATION# <br /> ( 416 ) 910-8318 165-261-260-000 r—er <br /> PHONE#2 EXT. BOS DISTRICT �5 / LOCATION CODE <br /> ( ) vt J <br /> CONTRACTOR/ SERVICE REQUESTOR N 0w--''n <br /> REQUESTOR CHECK if BILLING ADDRESS 1 n O� <br /> cotll <br /> p <br /> BUSINESS NAME PHONE# EXT. 3�21 Za,?.3 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGENIENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTNIFN'r hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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 F DER-AL laws. hh <br /> APPLICANT'S SIGNATURE: � Via' DATE: <br /> PROPERTY/BusIN �� <br /> ESS OWN OPER\TOR/NIANAGER ❑ OTHER ACTHORIZ.ED AGENT❑ <br /> If.IPPLIC XT is not the BILL/.V(;PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORNIATION: When applicable, 1,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 ENV IRON MENTAt-HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. ] 2 <br /> TYPE OF SERVICE REQUESTED: VV d r Q� ✓�ICn 1/ Pir'l/ r� `er <br /> COMMENTS: <br /> '100r ��i l cry v�� �.tF, . �N e : C <br /> �w►'c�i.t S� Q'' �O 000 U 0 69� 3�- <br /> ACCEPTED BY: EMPLOYEE#: iJ" DATE: .:3 �Q 2 <br /> ASSIGNED TO: EMPLOYEE#: DATE: 3 /Zl/ 0,3 <br /> Date Service Completed (if already compte ed): 2 Q SERVICE CODE: 72 PIE: <br /> Fee Amount: Amount Paid 2 f 2 q e-&— Payment Date <br /> Payment Type �' Invoice# Check# O Received By: <br /> ILAJ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1 1/1 712 00 3 <br />