Laserfiche WebLink
SERVICE REQUEST <br /> Type of Business or Property FACItJTY ID# SERVICE REQUEST it <br /> �r�:oo�r¢SSS <br /> OWNER!OPERATOR p Vk l ti ew" CNEacIf�tLLu�c ADD�ss� _ <br /> W—N{L%( ?9 <br /> ,d yEbIii . 1�kc*-vIL.t-E �• GtrE1K NTS ZM-Cade <br /> F <br /> hI �r_ADDRt:sS (If DHferent from Site Address) o.p r{ tV R--( LJ-3. <br /> s< <br /> �ITr SPS QftiWi o+.! STAT£Cjp, Zip 44'T13 <br /> IaHOHE#1 ExT. APN# LAND U58 APPt"MON# <br /> CAWS) 8 t&-tots amt -t I o& + - z[o �/,�- Gf-�'� �s <br /> PHOK#2 BOS DISTRICT LOCATION Cane <br /> ---. : - a_ .CONTRACTOR-/SERVICE "QUESTOR _ ...� <br /> REQUESTOR 0iE-cx if n� <br /> Pc8t3y �cc� . <br /> EXT. <br /> EWMNM NAME wgc-Of'c1L T N4 1htolE# 3�4^O3 f <br /> FA%# <br /> KONE Or MAILING ADDRESS (n`1 <br /> a{�DLw-:t- W• OPS 1� ST- cum) ' " <br /> C.fTY ('ot7j\ STATE C A <br /> ZIP q S- t7 <br /> g G ACKK.OWLKO-9EMM: I, the undersigned property or business owner, operator;or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIItONMENTAT.HEALTH DEPART MuNT hourly char86 associated with this project or <br /> activity will be billed to me of wy business as identified on this form i <br /> I also certify that T have prepared this application an IN <br /> t the work to be performed will be done in accordance with all SAN JQAQU <br /> CouNTY Ordinance Cortes,,Standards,S an DBRAL laws. <br /> APPLICANT'S SIGNATURE: <br /> E: <br /> DATE. ! �/ l z Z,Off� <br /> (VTEt� NPROPERTY f BUSINM OGER 13 orom AjfmoRL7.tiD AGENT 13 <br /> If ApnrcANT u not the B71;,LkgPART1;proof of authorlrataon to sign is required Title <br /> Tp ;When applicable,1,U owner or operatdr of the property located at the <br /> above site address, hcreby authorize the release of any.and all results, geotechnical data andlo� envirownentaUsite assessment <br /> inforrnation to the SAN JOAQUIN CouN'T'Y ENviRONmiNTCAL HEALTH DEPARTMEPTi'as soon as it is available and at the same time it is <br /> provided to=Or my representative. <br /> TYPE or-SERVICE REQUESTED: ��1t�t� SEIR�f'tG�.-+r C PAYMLN <br /> � CAI��cfNl IJPtTI�ir►3 R-��OC�T <br /> X2 ' -7�2�7fi�� arm <br /> NOV 18' 2010 <br /> SAN JOAQUIN COUNTY <br /> ENMRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY' EMPLOYEE#: <br /> ASSMNED TO: . i SCp73`O . EMPLOYEE M ��ltL DATE. j( <br /> Date ServiCO Completed (If already completed): L� PtE 2-&03 <br /> Fee Ansauot: v"�4c , oto Amount Paid W payment Date <br /> Payment Type <br /> invoice S Check# T3 Received By: <br /> Sit FORM(Golden Rod) <br /> FID 48-02-025 <br /> REVISED 11/17/2003 <br />