Laserfiche WebLink
Ji11V .JVi1l1UIIN UIN1 Y 11INV tICVLNNIUIN 11%"111:AI,III LL'1"A ICIAMINI <br /> SERVICE REQUEST i <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �Tccs Srat�c� F ON' � 1 SR CO3i 3 <br /> OWNER/OPERATOR <br /> PVf i prod CHECK if BILLING ADDRESS <br /> FACILITY NAME Am, <br /> r <br /> SITE ADDRESS 4855 9� S fu LK0 n <br /> Street Number Direction Street Name CI ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT- APN If LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ExT. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESSE] <br /> BUSINESS NAME PHONE# EXT. <br /> �fcu� T�chnalo ;�r 6-7901aaI <br /> HOME or MAILING ADDRESSFA%# <br /> 4 � lt,U3004 A (310 ) 0-79 q ,/ 1- <br /> CITY i �d+6o r o l; q0-50 <br /> 0-50 STATE ZIP <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 HEALTII DEPARTMENT hourly charges associated with this project or <br /> 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 laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER OTHER AUTRORIZED AGENT <br /> If APPLICANT is Hot the BILLING PARTY proof of authorization to sign is required Title <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 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: USI ( t h fvt; f'I r <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> Srp 0 . <br /> SAN JOAQUIN UOUNTY <br /> q ENVIR Slntw :LAPPROVED BY: EMPLOYEE#: '�' 0 -) r1ATENppf^ITO:f f IT <br /> - <br /> ASSIGNED TO: �,�y;� _ EMPLOYEE If: yy:1 0 �ryy DATE: Ott - 3o <br /> Date Service Completed (if already completed): SERVICE CODE: Nle PIE: �3yTr- <br /> Fee Amount: 0 Amount Paid Payment Date V V <br /> Payment Type Invoice It Check# Received By: <br /> EHD 48-01-025 "C2fiERVICE REQUEST FORM <br /> REVISED 6-5-02 \\ <br /> ea <br />