Laserfiche WebLink
y <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE <br /> 7 REQUEST# <br /> PG&E Stockton Service Center /7c�W c CC <br /> l 'i I-7 <br /> OWNER/OPERATOR <br /> C-) 6CHECK If BILLING ADDRESS <br /> FACILITY NAME ' C; <br /> SITE ADDRESS llJJ�� /1 J-nc j. v� <br /> H�re�Number Direction �" Street Name Cit !` ' / Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3 q n/ n��� <br /> Sttrreet Number (.� Street Name/ r <br /> CITY nA STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (uq ) g 4 �> J 17 v.-;-) G 0 I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Eric "Rick" Montesano (Agent) CHECK If BILLING ADDRESS <br /> BUSINESS NAME ' <br /> # EXT. <br /> Paradiso Mechanical Inc. N 614-8390 104 <br /> HOME or MAILING ADDRESS FAX# <br /> 2600 Williams Street ( ) <br /> CITY San Leandro STATE CA Z'P94577 <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 /> 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, AT`E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: . \/, DATE: ( 2—/-2- ('.,^� <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANA R El OTHER AUTHORIZED AGENT ❑ yP. J• P s , <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. (( 11 <br /> TYPE OF SERVICE REQUESTED: l_,4 j--T— <br /> COMMENTS: <br /> TCOMMENTS: <br /> /.�'��o ? 416► <br /> �R NM co <br /> Evr <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: ' EMPLOYEE#: DATE: -a •/ <br /> Date Service Completed (If already Completed): SERVICE CODE: P/E: <br /> Fee Amount: '') Amount Pai I'7 OD Payment Date J l <br /> Payment Type ✓ Invoice# Check# G2-165- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />