Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> R-&T-A, 1 L F U E L 37 8 s?-0 6 5 35�1p <br /> OWNER/OPERATOR <br /> "t) a IZ-t2„Fir( L IP P l•�=R— CHECK If BILLING ADDRESS <br /> FACILITY NAME AAA, <br /> 2� t4- <br /> / <br /> SITE ADDRESS r Y,K �p OA/,,R.G bk I- A,(,t S TO C1/- 'r 0 VA 9 S Z ( °( <br /> Z �-0 ( Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 7 <br /> PHONE#2 EXT• BOS DISTRICT -3-7LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I C �'t p'��- (/{/I `' I' ^ <br /> VIA l I`t L T-O CHECK If BILLING ADDRESS <br /> BUSINESS NAME I 1 A`-�0 /'�( � t r �+ PHONE# EXT. <br /> W l 916 <br /> HOME or MAILING ADDRESS FAX# <br /> ?- (y16 ) - 10- L <br /> CITY A-e— V 6�0� STATE C A ZIP '?'9-6 c?. <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application am that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and EDERAL la s. <br /> APPLICANT'S SIGNATURE: DATEE:j 3 /'C /C <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR/MANAGER OTHER AUTHORIZED AGENT Lbl C Oµ�2 d(7y rL- <br /> If APPLICANT is not the BiLLINGPARTY.proof of authorization to sign is required Title <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 HEALTH 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: PL p rJ 2 E-V l F.ttl /l( S f�F�c�/Q► F,-%K <br /> COMMENTS: r.ItUEIVED <br /> MA/y- 1 G U6,a <br /> SAN JOA <br /> QUIN <br /> flEN ROHM COUNn' <br /> LTH pEP FNTgL <br /> ACCEPTED BY: Q L( r l .� A EMPLOYEE DATE: /�. 0 /y <br /> ASSIGNED TO: Vit" EMPLOYEE#: Ey DATE: �L}� <br /> ��( �C4 J <br /> Date Service Completed (if already completed): SERVICE CODE: /9 e P/E: <br /> Fee Amount: .3 Li, oo Amount Paid G Payment Date 3 �� O ,j <br /> Payment Type Invoice# Check# 8 Received By: W Cr-- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />