SU0003938 SSNL - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN CouNI'Y ENVIRONNIENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# ^cKIcULTURgt nPrv`. �rsr= z90- 10 SA003396F OWNER/OPERATOR C�ENv-� bTE"EUi yt CHECK If BILLING ADDRESS FACIUTYNAME (SAM£ A3 oW HERS SITE ADDRESS 6A KDALF- 95Z4'i Street Numberimt, Street Name city Zin Code HOME Or MAILING ADDRESS (If Different from Site Address) G R oot.,,t5 R oP.D 30407 1=AsT G R oo M R 0 PDAST Street Number Street Nar[ce CITY C5AK13ALE STATE CA ZIP 9YJ3�) PHONE#1 ET. APN# LAND USE APPLICATION# (209 ) 847EOWA 2o7-29a-1r PA C20053 + PHONE R Ez. BOS DISTRICT LOCATION CODE ( ) t4/A CONTRACTOR/ SERVICE REQUESTOR REQUESTOR p WAL-F�R, {= GUSZTIS CHECK if BILLINGADORESS BUSINESS NAME CuR-rI5 s=ry C-tIN e>=RItJ C, PHONE# En* ZO'a 368-415 Nq HOME or MAILING ADDRESSFAX# 418 MqT rN _y_l PLAZA CITY L O p I STATE GA ZIP 9524-D D BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or autborized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charge9 lsso .ted with this projector 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,STATE and FEDERAL laws. APPLICANT'S SIGNATURE: ttiez�� DATE: M""Y Z7, PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ C Int I L E IJC t I-i E FR If ADPL/CANT is not the BILLING PARTY proof of authorization to sign is required eZ i1S� 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 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. ENS TYPE OF SERVICE REQUESTED: S3 Co. ReyeEW aF So 11_ Sv vTABt Li-TV ZkTUoy. RECE� COMMENTS: 13 ,p lsy 2 7 2003 �Id�,n3 ��✓ ll �C I33-1a" 1,11 NCOUNTY Q�M�^^� SP 61�H¢ALTSERH10ryS510N ENVIRONMENTPE HEPI APPROVED BY: I� II EMPLOYEE#: rL�5(� DATE: Z� , O ASSIGNED TO: �& EMPLOYEE#: '� uq 7 DATE: (, Ll O Date Service Completed (d already completed): SERVICECODE: PIE: Fee Amount: 1 Amount Paid Payment Date Payment Type Invoice# Check# Received By: EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02