Laserfiche WebLink
12/15/2015 11:19 209468: SJC EHD UNIT 3 PAGE 02/02 <br /> REGEIVYLL.i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST . g 2t715 <br /> Type of Business or Properly FACICfiY ID� C_lr W,,, VICE REQUEST� <br /> �OfimF L��4 �iPTAAPWT <br /> OWNER IOPERATOR � Cr+roxlfaituNyAooKEssQ <br /> Lei f <br /> FAC1ttrYh�AME . � . <br /> SrIEAt)DRESS x <br /> 3 IN-'�"8M§SL rr ' <br /> HOME ar KmuNo ADDRESS (If Dlffaront tram Bite Address) <br /> CITY STATE _ ZAP NOY 17 701 <br /> . APN# Lru+o USE APPucAUON#. ENVI RONME AL <br /> PHDNE til I Y <br /> X, elloo <br /> -� — 6000 1=AIT <br /> PNOMEli<2 pR, BOS t)L47RICT LOCAT70N CODS <br /> ( <br /> rul <br /> CONTR.A,CTOR!SERVICE REQUESTOR o ! <br /> REQUt397t3R C (^.— r n , CMECKt(t�JllJ.fHO eSS� <br /> J 1/ 'V � P E# Exi. <br /> Qus,rt>EssNAlue C— ,�C �//C �� -l7 4 <br /> HOME.or NWLINOI�L�+ � F <br /> / . C' c ' 1"t giI u <br /> CITY r O STATE Cx ZIP 3 <br /> BILLING ACKNOWLE,P_Q : I, the undersigned property or business owner, operator or authorized agent of ssma, " <br /> acknowledge that all eTt'e anddllor project specific EWRONMENTAL HLwALTH DEPARTMENT nourly charges associated with this project or <br /> actio*will the Drilled to me or my busineas as identlfled on this fom <br /> I also certify that I have prepared this application and that the work toperformed wA be done in accordance with an SAN JOAQV,4 <br /> CouvTv Ordfnance Codes,Standards,ST a WERAL IAWS- f <br /> APPLICANT'S SIGNATURE: DATE: to � <br /> PROP91M I(BUSINESS OWNER Q OPERATOR MANAOER CI OTHFRAUTHOIUMD AGtNT _� <br /> ffRPPLICANT 1S nG2 the B1LLip PARTY,proof of authorization to sign is required rias <br /> AuTtlg)_t ZA 014 TO RI3WE FNFQRl1lIATIDN: When applicable, I, the owner or operator of the property located at the above <br /> site address,hereby authorize the release of any and ali resuits,geotaohnlcal data areor envirorimentaUsita assessment infonrmtion <br /> to the SAN JOAQUIN COUNTY DmRoNMENTAI HsALm pFPAmvEw e8 soon as it i'available and at the same time It Is provided to me or <br /> my repmesentative- AW <br /> TYPE OFSERVICE REQUESTID: � '(� VE <br /> CoI�n�Nrs sL ! i'�v,..�• S rv- V lrtA t JA f r 0CT'2 8 2015 <br /> ( SAN JOAQUIN COUNTY <br /> ZWROMENTAL <br /> HEALTH MPAKT &ff <br /> ACct'_PTsD By: EMPLOYEE P. DATE:�a #S <br /> AS91riNEU TO: EMPLOy08 ilk OATS: d <br /> Date Service Completedl (if already completed): SEmnefiCOD£: FIE: <br /> Fee Amount: 3410•cD Amount Paid 301 J PaymentAata rte, at I t&` <br /> Payment Type Invoice# Check# G a Rec®hred By: <br /> EHO 48-02-025 SR FORM(Go(den Rod) <br /> 07117!06 <br /> Ci <br />