Laserfiche WebLink
SAN JOAQUrr.I COUNTY ENVIRONMENTAL HEALTH ✓EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Staff / 1 01f [✓a vuo �r<cr Al t s�6-0 70 <br /> OWNER/OPERATOR <br /> 4. of CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> C/K7R ar ll'4tvy4- a/• <br /> SITE ADDRESS c' C Y-mer o f F015/w•y a 6 Z <br /> i 9sa.de <br /> 191497 S[reet Number Direction [!kr'{ sf StreetName Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) t/� r .� 1 <br /> SS Street Number / / J7rIG/:beet Name SN bra !�Q <br /> CITY STATE ZIP <br /> F/CS/1 0 9J 7.,2 <br /> PHONE#t Exi' APN# LAND USE APPLICATION III <br /> (6.51 '/Y - -6.77i' 0q1 azo <br /> PHONE#2 Eu. BOSDISTRICT zA LOCATION CODE <br /> I ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINE SNAME /+ ] PHONE# <br /> G C O 4 fan YtS C - sa <br /> HOME or MAILING ADDRESS FAx# <br /> 3/6 o ZV alve �POo (9/6) &rte -9i3.z <br /> CITY /4?. 4U for VS STATE„ ZIP 9s�5/a <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 <br /> activity will be billed to me or my business as identified on this form. <br /> 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: / �1 =?� DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT IR nQ/Y.E ��n�r'. S!/✓. /y�� <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 <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS provided to me Or <br /> my representative. n <br /> TYPE OF SERVICE REQUESTED: u71 [ !•uxa/ SA,/-,e G A9n /C /' Rimm pae, � p <br /> COMMENTS: PA <br /> RECEIVED <br /> SEP 2 2 2014 <br /> SAN NVIAROMENTQUIN OAL N <br /> ACCEPTED BY: � vv ` EMPLOYEE#: pLTH <br /> ASSIGNED TO: Ilk EMPLOYEE#: DATE: <br /> Date Service Completed (ifalreadycomple ): SERVICECODE: j/t PIE: 2 3pL1 <br /> Fee Amount: 1� D Amount Paid 3TP � Payment Date o2� <br /> Payment Type ✓ Invoice# L Check# 4 R ceived y: <br /> EHD 48-02-025 L ` l e SR FORM(Golden Rod) <br /> 07/17!08 <br />