Laserfiche WebLink
09/26/2008 FRI 16:49 FAX 20941183433 SJC EHD 0007/007 <br /> `/ <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Ty of Business or grope FACILITY ID II SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> CHECK 11 MILLING ADORESSO <br /> FACILITY NAME <br /> SITE ADDRESS ' <br /> re Ion t e t <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number street Name <br /> CITY STATE Zip <br /> ON 1 <br /> EXT. APN# LAND USE APPLICATION# <br /> gj _2u3 - U&C) -/lc <br /> PHONE#2 Exc SOS DISTRICTLOCATION CODE <br /> I I 1 J <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME # Exr. <br /> H E f AIL <br /> UM <br /> CITY 12 U1W STATE ZI <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific,ENVIRONMENTAL HiiAui'Ii DEPARTMENThourly 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 1 have prepare is appliea'ol that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Sta dards,STAT fF ERAL laws. <br /> APPLICANT'S SIGNATU DATEE:�'. <br /> PROPERTY/BUSINESS OWNER OP ATOR ANAGER ❑ OTnE U'D10RI%EDAL'r.N'P <br /> /f APP7./CAA'T is not the BfLLIVr PARTY proof of authorization to sign Is rerpdrPr/I I Tule <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 ENVIRONMENTAL HEALm DEPAR'T'MENT as soon as it is available and at the same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: (�(,$'"r—F- -D F Tr— <br /> COMMENTS: JA <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: (/E( EMPLOYEE#: 3 DATE: g" <br /> ASSIGNED TO: EMPLOYEE#: s�l,f Z DATE: � Z�` O1 <br /> Date Service Completed (If alrea yoompleted): SERACECODE: D PIE. L1.6, <br /> Fee Amount:4 3 t S 0t� Amount Paid 3 S J1-3 Payment Date 6 <br /> Payment Type �/ Invoice# Cheek# �-�� Re eived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />