Laserfiche WebLink
JAN-17-2006 08:53 Service Station Systems 408 938 8888 P.04i12 <br /> SAN JOAQUI,. %.;BUNTY ENVIRONMENTAL HEA-LTH 1,— ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C,A'S S(A-Q0N' Aq W3o <br /> OWNER I'OPERATOR <br /> 4.O V 6S COWUTZ'� :51MI .E CHECK If BILUNGA.QDRESS0 <br /> FAciuTY NAME �t 1 C �N 2 Y 57OR6 <br /> SITE AD R`E�SS <br /> S .7 Stra umber Dire tl n Str4wt NaMo Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6 0 1 (3 U t KtA A"� <br /> t Yt Nu beratraal Name <br /> CITY 3" �105�- S�41zip qS�1 �... <br /> PHONE#1 EXT APN# LAND USE APPLICATION 0 <br /> (LAS �b3 g <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR M ART!7 A WE (TH M At CHECK If s LUKG_APD Ss z <br /> 5usmpss NAME -+� PH ExT' <br /> '3UV (R' Eta 'n 5 sf�ru S Y) a1-3 -k 03 g <br /> HOME or MAILANG ADDRESSFAx b 4 6 n-/� ( �#�) o;2.i3_ J cA O�> <br /> �l'tl��� �U�. tP <br /> CITY STATE ZIP gs' r <br /> BILLING ACKNOVFZEDGEMENT: I, the undersigned property or business owner, operator or authorised agent of same, <br /> acknowledge that all site and/or project specific ENVIRO`MI ENTAL HHAJ.TT: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 JOAQLTN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: f DATE: It 11'7/QUO sr <br /> PROPERTY/BUSINESS 0W',ER❑ OYk A o 1.t ry rHETt At:THO Z 1-MiNT�d C ( Ld oo►�C�9X6 <br /> IfAPPLIGANT is not the R11.1.7W7PAR7Y,proof of authorization to,sign is required rule <br /> A11THORIZATION TO RELEASE INIFt)RN)(ATION: When applicable, I,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 FrNVIRQNMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: i ^� -�.' <br /> COMMENTS: t n�U � 1 ( �Q S 7i I�1 l f)b 1 N <br /> �'p�c. �h-e e,-�' Oc.u�- t`C,•tu vim- �P i P cagy( k <br /> r ,.L r GLtr( S,Lylq-NS — I�n� <br /> te— SsTl7ur � W-b vl,L-{-OY'i Vq S LJS <br /> ACCEPTED BY: EMPLOYEE#: DATE. <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE' PIE: 2-3a <br /> Fee Amount: Amount Paid 1 a Payment Date l t Zz(O <br /> Payment Type ✓ Invoice# Check# I g[{-7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />