Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERI FACILITY ID#VICE REQUEST <br /> ( `7 Il/� <br /> Type of Business or Property �O Iv1 ART F V 0 v 1 V 5 Tb v 900 /�"I"1 7 <br /> OWNER/OPERATOR / -{ <br /> ASH ISN P�- O�/�Ti� CHECK If BILLING ADDRESS® <br /> FACILITY NAME tAY MINI MART <br /> SITE ADDRESS 1-7-5 /V I wILSnl J llOAy ST( C- l-FIl clSZUs <br /> S[reet Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (coq) 94I- 22.6/-1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (Lfos) 3 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR A.sHlsf-I �UV L_�� CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> M MINI MART kt)S2-04 — l _ <br /> HOME or MAILING ADDRESS FAx# <br /> CITY .SAr�I SUSS STATE CA ZIP 9 S133 <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: Lo-�C— DATE: 12- <br /> �z�/zo16 <br /> � <br /> PROPERTY/BUSINESS OWNER'WIy OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: U PAY <br /> COMMENTS: „, 1 O _ f �O� Ve <br /> Nye/ Wrif/, DEC272ol <br /> SAN JOAOUIN <br /> HEALTH 1) N qi ry <br /> ACCEPTED BY: n EMPLOYEE III: DATE: I / T <br /> ABZill— <br /> Z <br /> ASSIGNED TO: aEMPLOYEEM DATE: 1-2- <br /> Date Service Completed if already completed): SERVICE CODE: U tr I PIE' OVZ <br /> Fee Amount: 7�G� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />