Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />.3)10 Vki 6()Y1Cc <br />FACILITY ID # <br />+ \),e u,.3 <br />SERVICE REQUEST # / <br />seco -79. V <br />OWNER / OPERATOR <br />To V/ y 126 a4./nAk <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />4VV-ei 1— 4 <br />SITE ADDRESS 2-g(31) <br />rAlkiie-r Street Number <br />I— <br />Direction <br />HZ-4r ci ivi q kia.. ._/ <br />It-IV--E1,--19:rtAT7---4. S:47)6-te--17-1- <br />City <br />‘; C -05— <br />Zip Code Street Name <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />40 t k-----1 Lk.) V__ i,LSS L' Street Number <br />I <br />Street Name <br />CITY <br />' k--i-z--1--\ <br /> <br />STATE ZIP <br /> <br />6,4 GI <br />PHONE #1 <br />( Zell) 6373 • ko&-"7 <br />EXT. APN # <br />j (-1- i C69-0 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATIO N CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />To V) •-t 1D6 vtGtivi-el vvi itic-1, <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />G V 1, ee 1 S VILNA/ <br />PHONE # <br />('714/ '-&7 - )D <br />EXT. <br />3 <br />HOME or MAILING ADDRESS <br />cut FiZET7 <br />FAX!! <br />‘-te- ti.."1-----N CITY ZIP Sr ly ._ <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 and FEDERAL <br /> DATE: <br />PROPERTY! BUSINESS OWNER 0 OP RATOB/r MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is pr to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: (Dr)ICI al C— -e- c/1 5 o4 ikeeel" <br />COMMENTS: <br />03041 <br />P.001/4 G Ifkl• ,..geg. - ,t,fr <br />Dr-it0Cwi,PPall/t <br />V‘03:C10 <br />ACCEPTED BY: 16 (4 EMPLOYEE #: DATE: 55 . j...6 . / s.' <br />ASSIGNED TO: H-lx LA n h EMPLOYEE #: DATE: ..4C) - 1 <br />Date Service Complete ' (if already completed): SERVICE CODE: 0 Q„ j PIE: 1 <br />Fee Amount: i * Amount Paid 4, 52 .00 Payment Date S, 2c. \ <br />Payment Typeb+ Invoice # Check # Received By.(atZ) <br />APPLICANT'S SIGNATUR <br />Title <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)