Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I?OJ boZ1 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS El <br /> FACILITY NAME 1?o Nr>L VJ 1 rJER�} <br /> SITE ADDRESS (AV,S V , -C-UV- f-e- CZD • LOUI x57-42 <br /> Street Number Direction Street Name Ci Zi <br /> p Codt <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 133 0 {-FAST E12- l'a V G <br /> Street Number Street Name <br /> CITY 5 Fvr j. Jose STATE to ZIP at S 1'2-(.0 <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> (40tSk- }33to 015- os-D-I{1 PIN-1000051 (S#s) <br /> PHONE#2E-T' <br /> BOS DISTRICT LOCATION CODE <br /> -.&(p-4}S46 G4t1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> pR�tG W ELGIi <br /> PHONE# - EXT. <br /> BUSINESS NAME <br /> U J� O+�k- G-eo ENQ12oN IKEN'1 r\L-- 7,rlq 3(09- 03•}r <br /> HOME Or MAILING ADDRESS FAX# <br /> 40-+ w• 0Rr— �• (z.") 3b9 - 01 <br /> CITY Lo171 STATE CA ZIP 9 o <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 or <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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL la s. <br /> 7 1 <br /> APPLICANT'S SIGNATURE: 1 � l ill l DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OWER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization f0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 enviromnental/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 mc or my representative. <br /> TYPE OF SERVICE REQUESTED: ?4W,EtA) S,�fO I L S V ITft ES I L-1 �N IrR'�Tt% l.•ohbl rJG- Sr(v�`Dynn <br /> COMMENTS: <br /> JUN 2 2 2010 <br /> ENVIRONMENTAL HEALTH <br /> PERMITISERVICES <br /> ACCEPTED BY: /1 EMPLOYEE M 3 DATE: <br /> f'1 EMPLOYEE#: DATE: <br /> ASSIGNED TO: � (tel v <br /> Date Service Completed (if already completed): SERVICE CODE: �v PtE: 7/ <br /> a <br /> Fee Amount: S71 , Amount Paid - S j Payment Date 6 e Z : O <br /> Payment Type Invoice# Che k# (� Received By: <br /> SR FORM(G den Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />