Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> V-Opnk .i C ?AT0)-1 k&f_ / "T.] �rp��,'J�• � CHECK If BILLING ADDRESS <br /> FACIUTYNA�1�'MIIEII YY�cVDLOwo.Jl K`G 's rc`er7 <br /> SITE ADDRESS 3242- 47040 T U We q� <br /> Street Number Direction "1 �'rl�� Street Name'f/ cityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2318- Cf) . L' 10jo Oft— <br /> Street Number Street Name <br /> CITY f1 dJ� STATE ZIP <br /> 1 �7 CR <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (So) Ss16 Z?,r)� <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 120 <br /> 9MT I" QGUI. rfa CHECK If BILLING ADDRESS <br /> BUSINESS NAME y "D_ � I V PHONE# EXT. <br /> Tr �� o —,DPl _m LLC PROF pot-V4 I SO 8l6 2-'S21 <br /> HOME or MAILING ADDRESS FAX# <br /> 2'i 1 ir CAIZO,,- /p i Dv"- ( I <br /> Cm STATE nd ZIP 11 <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 <br /> or 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 /> APPLICANT'S SIGNATUI-R/E:: DATE: C)I/a1O, <br /> /1 L <br /> PROPERTY/BUSINESS OWNER I]0 OPE ORI MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> /f APPLICANT is not the BILL G 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it Is <br /> provided to me or my representative. \ <br /> TYPE OF SERVICE REQUESTED: ,(��. � Liu L (J`/-- <br /> COMMENTS: <br /> SAIVAIV <br /> jo 2 91016 <br /> EIyV,QQUyy <br /> NfALT/i0�ASH q�Nry <br /> ACCEPTED BY: `` EMPLOYEE#: DATE: I/Z cl ( l,'- <br /> ASSIGNED <br /> oASSIGNED TO: ,v C'C A IVks�/(VY� EMPLOYEE#: DATE: <br /> Date Service Completed (N`already completed): SERVICE CODE: SG C &J PIE: <br /> Fee Amount: 7C CA) Amount Paid �� Payment Date 24 <br /> Payment Type �,/ Invoice# Check# 5-37 Recelv6d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />