SU0008656 SSNL - Laserfiche WebLink

Home Browse Search

NAN JOAt2UIN k-A JUN"CY r,NVIKOiNMEN'IAL ULALI"H "EPARI MLN I SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# 3 OWNER 1 OPERATOR C.tt210.T C.VAps; C%_t CfzL L_Uq-IfCgAIsJ Ctt1 p—ctA CHECK if BILLING ADDRESS® FACILITY NAME C1ST E 1ltIVGELtC�kL t.VT'llit-19AN CtYtI9<C SITE ADDRESS ,?>p 2.1 hs. �4-D E4e81-1-R-I C-T• 1,,,-ODI Lf S'2.`f-Z- Sheat Number Direction treName Ci C 0,10 HOME Or MAILING ADDRESS (If Different from Site Address) �O S CEJ\J.jI?-fl L A�(E Streat Number treat Name CITY Le7at STATE L_e, ZIP S Z b PHONE#1 E.T. APN# LAND USE APPLICATION# (toy) 3i9�-(ozso oS�-o50 - t PA- o90©293 PHONE#2 ExT. BOS DISTRICT LOCATION CODE CONTRACTOR l SERVICE REQUESTOR REQUESTOR (l//y�-t7�J3 T� p q (2_A p�T,e"C-0 CHECK if BILLING ADDRESS BUSINESS NAME LtvL PHONE Exr. ZoR 3(ocl- 03-+5- HOME or MAILING ADDRESSFAX# t!o tri ,mow ST• ( zoy) N-9 - 03-1-+ CITY L_VC) STATE C:_p, ZIP ctS2fU BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form, I also certify ra that I have prepared this application and that the work to be perforated will be done in accordance with all SAN JOAQUIN COI1N'rY Ordinance Coder,Standards, STATE and FLDFRAL laws. APPLICANT'S SIGNATURE: J <'„ f rt u _l�2S D4TF: /4 --17— f 2 PROPERTI'J BOSINh:$$OWN'H2OPERATOR)MANAGER 0T7rER A2TNOAIZ.ED AGENr❑ q.'I PPLICANT is not the BLLLAG PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment intbrination to the SAN .IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same tine it IS provided to me or my representative. TYPE OF SERVICE REQUESTED: /2CVI E'^D SO((- SU 1 Tft3 i L I T y/ n)1 TR-14TH Lz),Art>J NG S?TV"D COMMENTS: PAYCCE NT �tt OCT 2 A 2011 ACCEPTED BY: Lt- EMPLOYE£#: DATE: ASSIGNED TO: {{ 11 p T EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: r� Fee Amount: ''" Amount Paid Payment Date Payment Type Invoice# Check# Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11117!2003