Laserfiche WebLink
A SAN JOAQUIN COUNTY ENVIRONMENTAL HFALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Susiness or Property FACILITY ID# fl ��SEIWCE REQUEST#OWNER 1 OPERATOR <br /> 2A. Er <br /> FACLIIY NAME <br /> SITE ADDRESS <br /> 19 S,.., o J a r k-T•n�. Rd • Mq �� <br /> HOME or MALWG ADDRESS (If Different from Site Address) <br /> Street Number Slrce!Name <br /> Cm STATE LP <br /> P14DWES1 Fxr. APN0 LAND USE APPLICATION <br /> (aa ) - a • 38 <br /> PWME#Z BGS DIS RtCT LOCATION CGDE rN <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR G <br /> REQUESTOR , <br /> CHECr(N BILLl10 AeDFtE39 <br /> ROSINESS NAME PHONE# ." <br /> 't _ <br /> HOME or Md�AILLIry�IN�GG ADDRESS FAX S <br /> r'Jrr1/ ( ) <br /> Cm 5 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of some, <br /> acknowledge that all site and/or project Specific ENVDtoNMENTALF[v LTH DEPARTMENT hourly charges associated with this projector <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 perforined will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Coder,Standards,STATE and FEDlaws. <br /> APPLICANT'S SIGNATURE: ` DATE: �J' - )-�4 <br /> PROPERTY]BUSINESS OWNER PP"RATORI GFA ❑ .OTHER AUTHOR1zE.D AGENT 11 <br /> IJAPPLIGINT IS not Ihe&U.0 G PARTY.proof of authorization to sign is required Thle <br /> AUTHORIZATION TO RELEASE INF'ORAIATION:When applicable,I,the owner or operator of the aced at the <br /> above site address, hereby authorize the release of any and all results, geotochnical data and/or en ®sessmeht <br /> information to the SAN JOAQUIN CGUNTY ENviRoNmENTAL HEALTH DEPARTMENT as soon as it is available same tithe it is <br /> provided to me or my representative. ZQQ4 <br /> TYPE OF SERVICE REQUESTED: t;Lct u,/A S71E- NL—A--J cE-IvE CC- �1NTY <br /> COMMEI1rS: <br /> F1EL0 ASO SF TG ]74r /� MEET -/1� rN 5 7 -4C'C-qr <br /> X26 PD s£o ^'E� o4-�d/T7[i n7 . s'/Zoe YL•�• .••tee/ <br /> D <br /> ACCEPTED BY: LI&I+ EWLOYEE#: G J 2 ys1 DATE: 'S-11110!4 <br /> ASSIGNER To: � ry � EMPLOYEE$: 4DATE, <br /> Date Service Completed (if already completed): SERVICE/ CODE: 0& PIE: rf2.,oL <br /> Fee A.moUnt: _ 73,w Amount Paid Gt3. Payment.Date (). <br /> Payment Type � Invoice# Check 0 ��„ Received By. <br /> EHD Aa-o2-025 SR FIRM(Golden Rod) <br /> REVISED 11117/2003 - - <br />