Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> R E STA UKR01�P06"-b 7A'&i1= P, A) IqOo I Wqk C-0077g5'� <br /> OWNER I OPERATOR <br /> p n/W + E k 0, ` CHECK If BILLING ADDRESS <br /> FACILITY NAME T 098 LP12-7-09 <br /> ' Z2 09 <br /> SITE ADDRESS N W I L 0 A RU F 97t ' U00 9 5-'361 ,50 6 <br /> Street Number Direction Street Name cityn Zi Cade <br /> HOME Or MAILING ADDRESS (If Different from Site Address) S H E U G A rE Gl&C-LE <br /> Street Number Street Name <br /> CITY STATE CP zip cJ f �. <br /> PHONE#t ExT. APN# LAND USE APPLICATION# C� <br /> PHONE#2 ExT. BIDS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTORCHECK if BELLING ADDRESS® <br /> N s <br /> BUSINESS NAMEPHONE# EXr. <br /> RI o ZA' >UL o e ABLE �-D 3 39 -S3 <br /> HOME or MAILING ADDRESS PI-22A FAX# <br /> L 7 C I ( ) <br /> CITY STATECQ zip 9y�' <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 Of <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,STATE and FEDERAL laws. <br /> )LAPPLICANT'S SIGNATURE: C�11o"M;C r C& CA�'L - DATE: d�� <br /> i PROPERTY I BUSINESS OWNER® OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />,i 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 /> to 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. <br /> TYPE OF SERVICE REQUESTED: ` 7� �yti 'Tlflt/� RAYMENI <br /> COMMENTS: G�tu� RECEIVE? <br /> -1 U I_ `' 4 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ItN <br /> ACCEPTED BY: Mu�rf,��c�l <br /> EMPLOYEE - L4,-1-7 <br /> ASSIGNED TO: EMPLOYEE#: DATE: -aA-1 <br /> Date Service Completed (if already completed): SERVICE CODE: 0&� PIE: 16 01)— <br /> Fee Amount: i vi-- 00 Amount Paid , "y 1 Payment Date 1 , <br /> Payment Type Invoice# Check# Received By: 4_w <br /> END 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />