Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> a2no�6.39�-- <br /> OWNER/OPERATOR <br /> fZA y rwE R CHECK if BILLING ADDRESS <br /> FACILITY NAME RAy - m mL iFA,;-tvl s <br /> SITE ADDRESS f"75-0 <br /> -.e 1 oin:ctlon - I <br /> tre me CRY ZID eoae <br /> HOME Or MAILING ADDRESS (If Different from Site Address) q D(o.4 'pODDS R.D <br /> Street Number Street Name <br /> CITY OAV-t>AL.E STATE CA ZIP RS3e1 <br /> PHONE#1 APN# LAND USE APPLICATION'# <br /> (201) 2.0-+-loo -o4 + - O(o -FA —/Q®O/lo0(id5) <br /> PHONE#2T BOS DISTRICTLOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> RBBy R1tG[..O CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# <br /> LIVE: OAK t;{pEJaJI(ZoNft1£tJTi�t_ 3(,9_oj }T <br /> HOME or MAILING ADDRESSFAX# <br /> tFo } W - ohlL ST. (70-1) <br /> CITY t_oD 1 STATE CA ZIP q�yytp <br /> BH,LING 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 or <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 JoAQU1N <br /> COUNTY Ordinance Codes,Standards,SPATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: r�/J / /( � DATE: 4) <br /> PROPERTY/BUSINESS OWNER® 46PORATOR/MANAG R ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT iS not the BILLLNGPARTY Proof of authorization to Sign is required Title <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 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 OFSERMCE REQUESTED: gr—%/tEN) SURYfMCE + SUDSvRFAC.E GONTA"?-JN1PtJ RT <br /> COMMENTS: / � RECEIVED <br /> f// ( JUL - 2 2010 <br /> SAN JOAQUIN COUNTY <br /> NVIRCNMF <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Lf V E f e r,- EMPLOYEE#: 0 3z-4 DATE: '741—/10 <br /> ASSIGNED TO: 7RL 11, jU m etcS EMPLOYEE M ,LIQ GIS"- DATE: -77Z /t O <br /> Date Service Completed (If already Completed): SERVICE CODE: 3/S PtE: a t,0-3 <br /> Fee Amount: 2-3 C Amount Paid 'Zk-p C) I Payment Date ''1 O <br /> Payment Type ✓ Invoice# Check# 0 31-7 O S-- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />