Laserfiche WebLink
AINJOAQUINCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT ` <br /> Type of Business or Property RE <br /> y SERVICE L <br /> REQUEST <br /> Facalrr ID# <br /> OWNER/OPERATOR SERVICE REQUEST# <br /> Ed Nicolay <br /> FACILITY DAME <br /> CHECK if BILLING ADDRESS ADDRESS <br /> 14539 E <br /> Street Number Louise Avenue <br /> HOME Or MAILING ADDRESS If Different on Street Name CI nt from Site Address) Ripo <br /> ( n <br /> 14551 E Louise Avenue, Ripon, CA 95366 <br /> ZIPCode <br /> CITY Street Number <br /> Street Name <br /> PHONE#1 STATE ZIP <br /> (209) 239-8995 E%T APN# <br /> LAND USE APPLICATION# <br /> PHONE#2 203-060-17 PA-_0$6037AA-r. <br /> ExT. <br /> ( ) BOS DISTRIC LOCATIQN CODE <br /> CONTRACTOR / SERVICE REQUESTO <br /> REQUESTOR .lames Robinson <br /> CHECK If BILLING ADDRESS X <br /> BUSINESS NAME JR Squared Consulting, Inc. PHONE# E.T. <br /> 209 772-3841 <br /> HOME or MAILING ADDRESS FAX# <br /> 6532 Mcneil Court ( ) <br /> CITY Valley Springs STATE CA ZIP 95252 <br /> BILLING 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 <br /> or activity will be billed to me my business as identified on this form. <br /> 1 also certify that 1 have prepared this applic 'on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes Standards , STA E. nd F RAI. laws. <br /> APPLICANT'S SIGNATURE: DATE: /I �-3 69 <br /> PROPERTY/BUSINESS OWNER OPE OR/MANAGER O THER AUTHORIZED AGENT <br /> tfAPPUCAA'T is not the 8/ NG PARTY roof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I 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 OF SERVICE REQUESTED: S LL 9,AS1,L C,) UT�A,( t OA d 2/ <br /> COMMENTS: t/ q'7 I p 'e- ( �: �,,.,,N.,��-��taKS� RECEIVED <br /> IIo� iy� NOV 2 4 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEhrr <br /> ACCEPTED BY: Q EMPLOYEE M ©3-2 Z <br /> DATE: (� 4 p g <br /> ASSIGNED TO: 7-4--ss 1 Oq/p 01.t_C_G S EMPLOYEE M .`s DATE: a 2-LF tag <br /> Date Service Completed (ifalready completed): SERVICE CODE: �S' P/E: 0p �oFJ3 <br /> Fee Amount: 2( � Amount Paid Payment Date \ o g <br /> Payment Type Ca- Invoice# Check# - Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod; <br /> REVISED 11/17/2003 <br />