Laserfiche WebLink
SAN JOACt..nol COUNTY ENVIRONMENTAL HEALTh EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />-F° c: .='• .-1-C6\ .; -cc- <br />FACILITY ID # SERVICE REQUEST # <br />C,:b <br />9- <br />,'s_,;'•:, ) <br />..., ...--, ) i <br />Ow ER /10PERATOR , <br />I—, e-fte_ 0 i C. '-' CHECK if BILLING ADDRESS <br />' Farm ITV IV ARNE ir <br />_C -4C-0 un_ <br />to A: -(2-_ ---i-J (0. -- I <br />SIT ADDRES5' .--fr-- <br />1 -------------------- Street Name Me)e .--S-710 <br />City Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />'14;75-.3-- <br />/ <br />Street Number 71---)14:( d 1-ifs Street kl;lai(m'e Y <br />R; v'ell-,40 K._ (5 <br />TATE ZIP <br />PHONE #1 EXT. <br />L 7 07) (0 cps - ‘..g_ <br />APN # LAND USE APPLICATION # <br />PHONE #74 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />RE9y,p7oR <br />e---ip,z_ -1>itt---. CHECK if BILLING ADDRESS, s <br />MI14E1 SS t lin c 0 0 n i. 0 6 a. , . --1- u 6, :.c 4....., \ ...,_ PHONEi <br />VO 4-, S—)-- — <br />EXT. <br />OME or MAILING ADDRESS <br />,--- 53.75-- '..-1,- .--4 d F07-e4 -7, <br />FAX # <br />( ) <br />ic e.:13:1f ci 1P--__- Lrl <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 a d FE ERAL laws. / <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />Title <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 iisilovided to me or <br />my representative. 8-59 , <br />TYPE OF SERVICE REQUESTED: ._.t... cc ' ici I 1 ( i U L._ <br />COMMENTS:- COMMENTS:AUG 0 1 <br />(t t i-tL <br />9 <br />4-ftio4QUIN <br />2017 i x 13,e - 8441 Jo I /*Zqt r Ronal couA,„_ <br />1'1 DEpApp Al.r.rAt 1 r - , ,A4Eivr <br />ACCEPTED BY: <br /> A jr-Ci <br />EMPLOYEE #: DATE: ..) i -7 <br />ASSIGNED TO: L , , ) 1 #: EMPLOYEEy,,A1,)ci DATE: - / 7 <br />Date Service Completed (if already completed): SERVICE CODE: r ' ?.... _2) PIE: i 147,(ji <br />Fee Amount: L kr)(1.- ' S9 Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />APPLICANT'S SIGNATURE: <br /> <br />DATE: <br />PROPERTY! BUSINESS OWNER.._ OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)