Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />.C31 16tCt 23 <br />OWNER! OPERATOR <br />VlL\ \Z(Q\ 1/4A CHECK if BILLING ADDRESS <br />FACILITY NAME 0\ -'‘Q--lA\--/-\ \--"° C CL-.. .4 LA yF, 3.q w \ <br />SITE ADDRESS (....0 2_0 <br />Street Number <br />S <br />Direction <br />G il cA/Arli-e,\Alro <br />Street Name <br />-A- • L c)ot.: <br />City <br />0 S7L-t-C) <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) -.2 coc_A <br />Street Number <br />V (/\ 11 'A-\-(\/\ cA . <br />Street Name <br />CITY Oyitk V STATE0A ZIP <br />PHONE #1 EXT. APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR _..4--- i <br />9 2.o c4 /1,-e., CHECK if BILLING ADDRESS <br />BUSINESS NAME Lok 4(2,kit, b,-. WC C& P.NNE # <br />(201 '12 — 3L 0 1EXT <br />-S 1 <br />HOME or MAiLiNG ADDRESS <br />--‘gicILLA \*1 CA— . <br />FAX # <br />( ) <br />CITY STATE Cyt ZIP Cte.Lp .3 L <br />BILLING A KNOWLEDGEMENT: 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 laws. <br />APPLICANT'S SIGNATURE: `A-6 l ec) <br /> <br />PROPERTY! BUSINESS OWNER OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> <br />If APPLICANT Ot 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 assessp , Irlformation <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is • ,r4fEitg or <br />my representative. Air <br />TYPE OFOF SERVICE REQUESTED: -_,,,,Dok. v,.2_,,A I ck,12_ \ of GV e Cil/t"-, DEc 1 <br />COMMENTS: <br />b,AAAJ2111-1LO - 81141 Jo ovilAQuitsi4c <br />2018 <br />kit40. Ro4,416, 0147), <br />11 DE734 ,21,7:41. , ,4%,117 , <br />ACCEPTED BY: \\( . MA)(212.Art ....D EMPLOYEE #: DATE: <br />ASSIGNED TO: 6). f tiy) EMPLOYEE #: DATE: <br />Date Service Completed (if already co pleted): SERVICE CODE: % \ PIE: 1(0 6 3 <br />/2 //34'7 <br />Received By:7 <br />Fee Amount: Amount Paid /5--, (:),z), Payment Date 2 C:r.-) <br />Payment Type zc- o__. Invoice # Ch,A #624,5-. ..7, <br /> <br />DATE: /2-- <br /> <br />Title <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)