Laserfiche WebLink
RECEIVED <br /> [,yA'1' 2 7 2014 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEENVIRONMENTAL <br /> SERVICE REQUEST HEALTH DEPARTMENT <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -:77 Y- 11 5/C 00 to 7 33 <br /> OWNER/OPERATORSU 1/' y� <br /> Y1 6hIALI Ctr- CHECK ifBILUNGADORE <br /> ss� <br /> FACILITY NAME ^t—� u, 0 Pi Pe <br /> tro I r_ L-t <br /> SITE ADDRESS 1 r) �� G �0 5-C rYl( t� ��� 1 ,Man-i-r & <br /> 7 S�j 3�j <br /> Street Number DI ctlon tre9tNd I Code <br /> HOME OF MAILING ADDRESS Jif Different from Site Address) <br /> Street Number Atrast Name <br /> CITY STATE ZIP <br /> PHONE'## Exr. ApN LAND USE APPLICATION# <br /> ga3..-4-7ls <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> { ) <br /> CONTRACTOR! SERVICE REQUESTOR <br /> REQUESTOR <br /> GtkC1-A0JA; f- CHECK if BILLING ADORE <br /> Bus MESS NAME Re;i i ckbv ) �'y -�,sE & <br /> � �1eu Serv1 ��s <br /> HOME Or MAILING ADDRESSt 1 9 3 o/� �O rC� j� � � � - FA%� <br /> I J 114?0-7 F y <br /> CITY ti A 1C t - /L L Y STATE CA zip § ` <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of some, <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 /> 1 also certify that[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: ==�R- � .- '� DATES/: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTIIER AUTHORIZED.AGENT L]f <br /> IfAPPLICANr is not the BILLING P tRrr,proof of Authorization to sign is rewired litre <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 HIZAI..TH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ' S LI—YYL s-e yls 0 w LZ:5 )rc Lau V <br /> Coefhtalrs: <br /> '51 P 5 LA yvp S-enso r Oa s re,,Lr C e04yMEI`#-h e_ <br /> RECEIVED <br /> MAY 2 8 2014 <br /> SAN JOAQUfN COUNTY <br /> ACCEPTED BY: QA G EMPLOYEE <br /> 1/ r <br /> ASSIGNED TO: MA . <br /> /\1 � EMPLOYEE#: DATE: <br /> Date Service Completed (if <br /> llalready completed): SERMCECODE: gy PIE: t 33 <br /> Fee Amount: "7S' Amount Paid Payment Date �ag' 14 J <br /> Payment Type(✓�i Invoice# Check# Receiv By: <br /> E:HD 48-02-025 ' 65�g 5 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br /> £'d £96896860Z LunelOa1ed elgeile2j 06'v:90 V I,LZ A13 V1 <br />