Laserfiche WebLink
t /19/2002 12:45 46401 ENVIRONMENTALWLTH PAGE 01 <br /> 6A.N JOAQUIN COUNTY ENVIK0NMEtN-I•ALk1UAUrJJ J)k%kA.ltTMbN-.- <br /> SERVICE REQUEST <br /> Type bf Business or Property .FACILITY ID'# :' SERVICE REQUEST# ' <br /> '. 031 3•I <br /> OWNER I OPERATOR CHECK If BILLING ADDREss❑ <br /> FACIt.RY NAME 6 <br /> T <br /> SITE ADDRESS y,, <br /> d /Street Number DVir`eatlon I"H rF�J Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Numbet <br /> CITY STATE ZIP <br /> PHONEM £xT• APN# LAND USE APPLICATION# <br /> .(ago!) <br /> PHONE#2 EXT. ..SOS UISTRICt <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> FZEQUESTOR+ ^ (� (\ CHECK If BILLING ADDRE&$❑ <br /> BUSINESS NAM' IU �- PH a�n�. <br /> c. LL Jn : <br /> HOME yr MAILING ADDRESS FAX# <br /> >_,\) /gl <br /> CITY `� ` `^^, ' STATE /1 ZIP d C <br /> DIT.LTNG <br /> 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 projector <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,STAT nd FEDERA ws. <br /> A�PLICANT'S SIGNATURE: � Cs DATE: <br /> PROF ERTY/IaUSINI b 0H'NER❑ O ERATOR/MANAGER ElOTRf A TItORIZEU AGE N��AI <br /> 7fAPPUCANTis not theBILLff r.,&RT7:proof of arithorilation to sign is require Title <br /> AUTIIOIZIZA.TION TO RELEASE INFORMATION:When applicable, 1, the owner or operator of the property located at the <br /> above site addiress, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMIrNT 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: <br /> COMMENTS: <br /> clo <br /> i i N Jo N P`N�P���pN <br /> ENv���NM <br /> ,APPROVED BY: . ,. EMPLOYEE#: Z) DATE ry ih1 <br /> ..u <br /> ASSIGNED TO: �...;. <br /> V r _ EMPLOYEE#7 > •..• DATE, <br /> Ax <br /> Date Service Completed (If already completed): Sf RYICE Cobt:: 'I b PIE. <br /> {� ,• <br /> Fee Amount: 2 `� Amaunt Paid .r' payment Data <br /> $ Received 3y:PaYant Type Check#voice# <br /> 9 <br /> EH0 4t4l-025 SERVICE REQUEST^RM <br /> REVISED 6-x-02 <br />