Laserfiche WebLink
JAN JOAQUIN I.OUN'l'Y Lt NVIKONMEN"1'AUMALIH IJEPAR'IMEN 1 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR o 1I��II <br /> DAN DV R S r CHECK If BILLING ADDRESSICI <br /> FACILITY NAME p 1 A Z A <br /> SITE ADDRESS 10111 <br /> Street Number <br /> Direction Street Name <br /> Ci Zip Codd <br /> HOME Or MAILING ADDRESS (If Different from Site Address) $IWAE <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#I EXT. APN# LAND USE APPLICATION# <br /> (Zpl ) 4(/3- 5-13'-F 01 a - I£ro- Iz PA-- 1000 2(94 <br /> PHOME#2 ExT. BO$DISTRICT LOCATION CODE <br /> (yoq ) (GO x-- 04(ng <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR A,F03y �-�O ❑ <br /> 7 CHECK if BILLING ADDRESS <br /> BUSINESS NAME UJI: Oft1L C7EOEhN(RoNWlEN'TAk.- <br /> PHONE# 3lnq- o3-fiS Ezr. <br /> HOME Or MAILING ADDRESS FAX# <br /> 40-+ (.�• OAK ST . ( ze°ry 31P9 -o3'a�- <br /> CITY L_OD( STATE G A ZIP G1 S 2•{'(J <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 /> 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,Stand��TE ananjd�FERE laws. <br /> APPLICANT'S SIGNATURE:i; DATE: <br /> IN9 I <br /> PROPERTY/BUSINESS OWNER OPERA2T�OR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTT'.Proof of aulkorizadon to sign is required Titre <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 t0 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: AE;V I ClA-? SOIL $J ITA31 t_ITy /NIT"T C LOACW O&. 5'TJD� <br /> COMMENTS: !b 1 I O /2�/(( PAYMENT14", /6'/Z,//J/ _ RP9CErxED <br /> �e �N�-"`., �'� SEP 19 2011 <br /> rr7" f sever <br /> 5aNpanuUnNCOUN <br /> I FNVRONNieNTAL <br /> n::.a�Tn car <br /> ACCEPTED BY: �" EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: SW DATE: <br /> T <br /> Date Service Completed (if already completed): SERVICE CODE: y2 P I E: Dti <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM( Iden Rod) <br /> REVISED 11/17/2003 <br />