Laserfiche WebLink
01/17/2007 11:38 2093331838 CHATFIELD CONST PAGE 02/03 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST 9 <br /> VCha � IC� II S oC� � yi � <br /> OWNER 1 OPERATO (3--5 ��` ► J �/e Yt 1�6f I I <br /> 1n f Ur CHECK it BI��tNQ ADORI.�$� <br /> FACILITY NAME [il y� �/� � n r f- <br /> SUE ADDRESS I yl OV�r ` h V v O �Lj r��DMLakcaUM <br /> � <br /> HOME or MAILING ADDR5 (If ON rent from Site revs]) <br /> iblast Numtmr SLNorw <br /> CITY STATE ZIP <br /> PHoNE#1 Ext. APN 0 LANo USE APPLICATION <br /> PHONE N2 Ex*. BOS D13TRicT LOCATION CODE <br /> CONTRACTOR J SERVICE R.EQUESTOR <br /> REQUESTOR ff <br /> n COh-,�-�47W(-h'on <br /> rl/ CHECK If 81LLIN6ADAR�SS <br /> BusINEss NAME Ex* <br /> PM <br /> * 33 3J )91 <br /> HOME Or MAILING ADDRESS * y l <br /> CITY STATE (J"f zip <br /> BILLING d EMENT: I, the undersigned property or business owner, operator or authorized agent of same, Q <br /> acknowledge that all site and/or project specific ENWRONMENTAL HEALTH DEPARTMF'NT hourly charges associated with this project <br /> or activity will be billed to me or my businrss 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 JOAQtmv <br /> CQI-FN ry Ordinance Codes.Standards STATE and FEDERAL laws- <br /> APPLICANT'S SIGNATURE: A NPW'PMATt 7" O �yI <br /> PROPRRTY/BS7N <br /> r,' R45OWNT.R BATOR/MANAGr,R O ()1• R Ar. (rRr7.&D Acv.NT V r J e l97l�, �h- 'a r(/('L <br /> If APPLICANT i.S not the BILLING PARTY,proof of authorization m sign is required T Title r'0n!!5v` <br /> AUTHORIZATION TO ULEA EINFORMATION: 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 COLiNTY E.NvIRONMLNTAL HEALTTI DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> I TYPE OF SERVICE REQUESTED: L-! u t Lt) to 7--4 /' A,-^J f t✓ G(C - ti 6-t <br /> COMMENTS: <br /> 0AIAID-1 <br /> ACCEPTED BY: & C ( �E I F%� EMPLOYEE#: DATE: -77 <br /> G� <br /> AS&GNEo Tv: -7W: I'L G1d L 6-SEM oYE�#: C( b�( C— DATE: 0 17 l O7 <br /> / <br /> Date Service Completed (N alnrady complsbd): SERVICS Coop: <br /> 2-2- P E: 42 G <br /> Fee Amount: 4 I vl 0,0 Amount Paid � 1 O. 0 C) Payment Date <br /> Payment Type G Invoice# Check# Received By: <br /> EHD C —7 <br /> REVISED 111/21712003 SR FORM(Golden Rod) <br />