Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />.7 GE 0216)i I/A TVIA C J(____ <br />FACILITY ID # <br />NW <br />SERVICE REQUEST # <br />( -zooL'l -1121 , <br />OWNER / OPEWOR <br />verytov-N -30,p. eo.../ 1.45.-- CHECK if BILLING ADDRESS <br /> <br />FACILITY NAME L../ , ,,, , <br /> <br />1 V / C., 5 -T-c. E 0.6--A-0---_ <br />SITE ADDRFiS , _ , I <br />- .,rection <br />g-CA <br />Street Name silaCIY-- <br />City ' Zia C;ocie <br />HOME Or MAILING ADDRESS (If Differentfr nxtAddress) 530a rYkr-54ra-4— Street Number Street Name <br />CITY 5 ti)c,K.4trx._ Cie:TATE Z1,96;20 V <br />PHONE #1 EXT. <br />poet If 60 —123L1 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR /SERVICE REQUESTOR <br />REQUESTOR <br />Verni)ft -1\ia31,1 -b!)1K-16- / VILLY ak 311c1DI PK. CHECK if BILLING ADDRESS <br />BUSINESS NAME Ps <br />(---11 Vt 4-s rce_ Cx-e-4 14,/— <br />uzg <br />(-0V Ltt•'. 047 341 <br />EXT. <br />HOME or MARAG ADDRESS <br />3oa roar50.4...c- <br />FAX # <br />CITY St)4A (--A1P------ STATE CA._ ZIP C:15--Do Li <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 thi a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar s, ST E and DERAL laws. ...), <br />APPLICANT'S SIGNATURE: Gt.) At 1...,-,--__ <br />DATE: <br />- _ <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is req uired <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 provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: h)0 (( Val i 6 IC Tilfre An <br />COMMENTS: V <br />AP;41Plfr:7E1:1 :7 <br />r..retrw <br />20 <br />SAN .1 _ -0AQuw <br />ENVIP0 1 '' C°UNTY , <br />ACCEPTED By: j\/,j,, ialiqKri,64-\ EMPLOYEE #: filWill ij ,a3 <br />ASSIGNED TO: 0 In in EMPLOYEE #: DATE: <br />/girl <br />P/E: 1003 Date Service Completed (ifi already completed): SERVICE CODE: , ,U Lij <br />Fee Amount: <br />41 1 Ci <br />Amount Paid -. ,...,,,9 „1-, Payment Date of _k L.4 \ \ 1 <br />Payment Type NI .50.._. Invoice # Check # Received By: ) <br />Poi'? <br />Title <br />END 48-02-025 SR FORM (Golden Rod) <br />07/17/08