Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SnERVICE REQUEST#,, <br /> I`.!��1 >)FJeI.01'NIFwT —C/l�l j SR06 -) V-79V <br /> OWNER/OPERATOR <br /> L R,A T7-F�.L j CHECK if BILUNG ADDRESS <br /> FACILITY NAME '-�4 <br /> � IDt7 InL�Sr scHul�i'� �Lcyy}p t TYL✓i-ry <br /> SITE ADDRESS <br /> iK�r�O ld . S�IaLJrlTN>r 21�. TFL✓+L � �' �3�� <br /> Street Number Directs n at Name CI Zip C a <br /> HOME Or MAILING ADDRESS (N Different from Site Address) I w1 I G��k-ffEL5an1 <br /> 3� Streber St Na a DV<1�♦: <br /> CITY STATE ZIP <br /> l R�IIwG Z�/ <br /> PHONE#tT APN# LAND USE APPUCATION# <br /> 201 zN o (�? /Z, a— <br /> PHONE#2T BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �t A��1Y �/)/)(,t�V�.�s CHECK if BILUNG ADORES <br /> BUSINESS NAME l V ,F PHONE# ExT- <br /> J CI lb � IZ GYJ Z <br /> HOME or MAILING ADDRESS FAX# <br /> L2 Baas c r ( ) <br /> CITY G I=}t^'rL L3-rJ �R''Z� STATE d ZIP <br /> t s � z <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 or my business 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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE a"EPAs. <br /> APPLICANT'S SIGNATURE: DATA) <br /> /E:: -Z Z/(J'�� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/M AGER ❑ OTHER AUTHORIZED AGENT Y3 CC•jr ..1 xi't S UL -� <br /> If APPLICANT is not the BILL/NC PARTY proof 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. pr <br /> TYPE OF*WMR BESTED: I L P� <br /> COMMENTR E C E IV E a•• <br /> FEB 15 2017 < _� � � �� 'y��✓��/� �. � 13 2 13 <br /> SAN JOAOUrN couNry E <br /> NVIROWENT <br /> EWRONMENTAL <br /> HEALTH DEPTEHT Gr�iti�L. - PERMIT/BERN m <br /> ARr-2- <br /> -7 110 mk9-Po <br /> ACCEPTED BY: -EMPLOYEE#: DATE: <br /> ASSIGNED TO: U U C EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): .J SERVICE CODE: P 1 E: y <br /> Fee Amount: Amount Pal �� UD Payment Date "7/S <br /> Payment Type ✓ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />