WORK PLANS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# 25fia �'^� (S'I�Yb�t ks) t S PCO OWNER/OPERATOR CHECK if BILLING ADDRESS❑ S'towb uc s c4m coul FACILITY NAME SITE ADDRESS 5010 4'U"t-( _S -��tr►1 `1'5110 Street Number Dlrectlon Street Name City n -tel Zi Code HOME or MAILING ADDRESS (If Different from Site Address) 12fo I U-t-� AVW�I�I JL- c�6v+` l Street Number Street Name CITY ^naW AE zlP i+ 111N PHONE#1 l t ExT. APN# LAND USE APPLICATION# PHONE#2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Tear C014+ZYVI D CHECK If BILLING ADDRESSES' BUSINESS NAME HONE# EXT, 1 14S Wry I t J'�� P.? 0 HOME or MAILING ADDRESS J FAx# I I 1 S w tri AV1L. t ) CITY �y'-"UL. STATE ^ ZIP 1po SOI BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL I IEALTII DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. APPLICANT'S SIGNATURE: ell DATE: I�A l!`� PROPERTY/BUSINESS OWNER El OPERAT( /MANAGER ❑ OTIn':R AUTHORIZED AGENT Q r��eCf Ai"' 'mr > if APPLICANT is not the II//`/./A(;P•UtT)'.proof of authorization to sign is required Tirte AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Xe time it is provided to me or my representative. 71ka TYPE OF SERVICE REQUESTED: S �.� neat L W COMMENTS: ti�N�R 0U,1? ?49/ +L-X-( I or CO—, I Pam r►� �`T"oF"FNo�N N ACCEPTED BY: �a��^� S EMPLOYEE#: DATE: / ASSIGNED TO: F-77 kyVl EMPLOYEE#: DATE: I i Date Service Completed (if a eddy completed): SERVICECODE: s-23 PIE: 1V Fee Amount: �� Amount Paid �,�v Payment Date l Payment Type ` Invoice# Check# )0Z�3s$-��'� RecAed By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003