Laserfiche WebLink
08/14/2012 17:31 9796959468 FREEBIRDS PAGE 02/03 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY I SERVICE REQUEST A <br /> Dub SSl 'ti <br /> OWNER I OPERATOR CHECK N BILLING ADDRESS❑ <br /> C c- — /d <br /> FACILITY NAME <br /> SITEADDRESt /q�p �/ //�Ja. �S e Tra 9S.f 76 <br /> alrsel l Ceee <br /> HOME or MAILING ADDRESS (If OlNemnt from Slte Address) <br /> (y 4 A 960 Semi Number t ame <br /> CITY �M_ _ STATE LP <br /> E/// �/ Z <br /> PHONE A7 Eu. APN M LAND USE APPLICATION It <br /> (S/o)-5,7q. 11nf� <br /> PHONE#2 in. BIDS DISTRICT LOCATION CODE <br /> z I Wq- 6—Aa2. — i <br /> CONTRACTOR/ ERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BIW NG ADrrRE3s <br /> BUSINESS NAME PHONE II En_ <br /> HOME or MAILING ADDRESS FAxO <br /> 1 I <br /> CITY STATE ZIP <br /> AILLiNG ACKNOWLEDGEMENT: I, the undersigned properly or business owner, operator or authorized agent of some, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH 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 preparedthis application and that the work to be performed will be done in accordance with all SAN JOAQUw <br /> COUNTY Ordinance Codes,Standards,STATE.and FEDERAL laws. p <br /> APPLICANT S SIGNATURE: L� a iJ DATE: TT0-- �7,-_ _ /����1�� <br /> PRDPRRTT/RUstI OWNER❑ OPERATOR/MANAGFA ❑ OTnr:R AtrimoarzED AGLNT /M LtrV-A <br /> If APPLICANT is not the RrT.T WC,PAR T1:proof of authoriZaI t0 Si_ iS retJuire ��'"'mere <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 enviromnemal/site assessment <br /> information to the SAN JOAQIJIN COUNTY ENVIRONMENTAL HEALT7t DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. P= 'Y V,E NT <br /> TYPE OF SERVICE REQUESTED: R�-i; I`Y7r r <br /> COMMENTS' / , lJ AUG 14 2012 <br /> SAN JOAQUIN couNi <br /> EWRONMENTAL <br /> HEALTH OE�ARTNE� <br /> ACCEPTED BY: ENPLOYEE 0: DATE: Y <br /> ASSIGNED To: EMPLOYEE#: DATE: <br /> Date Service Completed (Ir sheady complefed): s--Ce CORE: 6W PIE 0-y <br /> Fee Amount: Amount Paid 19 (D�S- D-0 1 Payment Date <br /> Payment Type fil,1 C I Invoice# I 4 Check 4 Received By: <br /> EHD 49-02-025 ` / SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> Received Time Aug. 14. 2012 3: 36PM No. 0852 <br />