Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />rroSita r000 FA r RA I LER <br />FACILITY ID # SERVICE REQUEST # <br />DZ,D0 17070 <br />OWNER! OPERATOR <br />CHECK If S roc tc.ro t•-) Del. 14 2 E-Sc,g7" i 4 C <br />BILLING ADDRESS <br />FACILITY NAME 5 To cm ra to /Arc r4 pe30 a 7- <br />SITE ADDRESS <br />/if 90 0 Street Number <br />W <br />Direction <br />HiGHwAY 1.2 <br />Street Name <br />LaDt <br />City <br />9 Co24 2 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Crrv STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 En. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />IA CUSTZ) n FO 6 0 TRUC/CS <br />BUSINESS NAME <br />2 CHECK It BILLING ADDRES <br />P <br />ZI <br />V/14 r 6 IZ (14 l ' 0202 .5- - 01/7 <br />EXT. <br />HOMEirtkup:,:DREZt gt_vo Fo # <br />( 1 <br />CITY S YI 1742 STATE cif. ZIP 9 34.0z <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 and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br /> <br />a 424h7 <br /> <br />DATE: <br /> <br />PROPERTY / BUSINESS OWNEISQ OPERATOR/MANAGER El OTHER AUTHORIZED AGENT 0 an utiPerA <br /> <br />If APPLICANT is not the BILLING 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-1-frALTH DEPARTMENT as soon as it is available and at the same time is <br />provided to me or my representative. E ivED <br />2017 <br />Co, <br />fri7;44"-tY <br />7-kgEw.r <br />"-U <br />TYPE OF SEM/10E REQUESTED: 1-7013 I j. FOOL pi. h si-, 0-1E-CM <br />4 fAR COMMENTS: 2 <br />_5170 k e- 4-6 pp. Pei v...ae.,aia luo 0..ie ,4xe 4404 Me 7444k* <br />---p?-i.....417 4,4, eyed/6J 1714- 044...../e0N: o 3/.1-4// 7 •• 1 6,7 S. 5-th;Co&Aite: ODZ 4 0 0 r" (WY, <br />ACCEPTED BY: EMPLOYEE #: ( .4/ 3 DATE: 2 7 /, 7 <br />ASSIGNED TO: tftor k , EMPLOYEE #: ?C.! Ct7 DATE: 3/21 // 7 <br />Date Service Completed (If already completed): SERVICE CODE: ffli - PIE: i (,c, / <br />Fee Amount: 6.c. Yr) Amount Paid 6,25. (_...) Payment Date ,a, 7 <br />Payment Type /2. Invoice # Checii# t 0.24 31 0 Received <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)