SU0004529 SSNL - Laserfiche WebLink

Home Browse Search

JAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# "-< FN AZ- 7,9 SF Co �/A S Sly OWNER/ OPERATOR CHECK If BILLING ADDRESS 1271Z. 7 AI /N FAcftm NAME - T �y SITE ADDRESS 3703 W1:sT- &ANT L/n/E 7RAe 753 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 EXT' APN# LAND USE APPLICATION# ( Z01 ) 79/ a / - a70- -PA -o 4 - 3st 2-F) PHONE#2T• BOS DISTRICT LOCATION CODE ( > 321-251oz g� CONTRACTOR/ SERVICE REQUESTOR REQUESTOR O� ^,l�s�/C CHECK if BILLING ADDRESS BUSINESS NAME 1/ `// L PHONE EXT' ClgFsnrE -7-1 Al Zrrq G8_ -4V3 HOME or MAILING ADDRESS FAX# Po . Box 37p ( ) 6G8-zs98 CITY �uRLO STATE CA ZIP 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 that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,S and FAL laws. APPLICANT'S SIGNATURE: DATE: T— a? - O 7 PROPERTY I BUSINESS OWNER❑ OPERATOR AGER ❑ OTHER AUTHORIZED AGENT K1 If APPLICANT is not the BILLING PARTY,proof of a horization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,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 information 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 my representative. TYPE OF SERVICE REQUESTED:All TR /N SOI L $d/iq L STUD/OFS RE I//E COMMENTS: 7 /p p}7 - �� / RECEIVED -746 ) Q,eUIE�ta 641hLc41® JUL 3 2007 SAN JOAQUIN COUNTY ENVIRONMENTAL ACCEPTED BY: 0(_t t=t e A EMPLOYEE#: O 3 DATE: -7 �5 Q ASSIGNED TO: —r�A'S I O 7E)LtA- VS EMPLOYEE#: I-F(J aLs' DATE: -•7OIJIVZ Date Service Completed (if already completed): SERVICE CODE:( Jc-�S PIE: 9_G02_ Fee Amount: 4;-75- 'Y� I Amount Paid -7S' Payment Date `7 l3( 6-7 Payment Type Invoice If Check Received By 7 EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003