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x <br /> SAN JOA?N COUNTY ENVIRONMENTAL }DEALT( <br /> DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID A SERVICE REQUEST# <br /> o SkO 07 �Z <br /> OWNER 1 OFERATC)R <br /> CHECK if -I-LING ADbftE55 <br /> FACILIPI NA <br /> ar`'�` <br /> SITE ADDRESS <br /> Street Number Direction <br /> S Street Name � itv Zi❑Cp@� <br /> How Or P1+IAILING ADDRESS (If Different from Site Address) �7 �jL 4 A <br /> CITY ` Street Number Slreet Name <br /> STATE Zip <br /> 3 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (33o Z� <br /> PHONE#2 EXT. <br /> SOS DISTRICT LDCArIDN CODE <br /> f ) c40� <br /> COI TRACTOR/ SERVICE R QUESTOR <br /> REQLIESTOR �� <br /> CHECK if SILLING ADDRESS <br /> $USINESS NAME PHONEEXT. <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE zip <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 also Certify that I have prepared this application and that the work to be performed will be done in accordance vvith ail SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: .— <br /> DATE: <br /> 1-2t� /15-7 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I 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 environmentallsite assessment information <br /> tc the SAN JOAQUIN CouNTY FNVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: f d r <br /> COMMENTS: <br /> .VtJ n r�>,M9✓ 'r /�j �� <br /> JAN, 2 6-2G15 <br /> I SAN JOAQUiN <br /> COUNry <br /> LTH �HEA � AaI <br /> IWENr <br /> ACCEPTED BY: ENIPLOYEE#: DATE: 1 7 J <br /> ASSIGNED TO: EMPLOYEE#: DATE: Ub <br /> Date Service Completed (if already completed): SERVICE CODE: d[! P/E: 1 le p Z y <br /> Fee Amount: �� Amount Paid �;� Payment hate <br /> Payment Type Q Invoice Check 4Received Ey: <br /> EHD 48-02-025 SR FORMI(Golden Rod) <br /> 07/17/08 <br />