Laserfiche WebLink
Jul. 10. 2008 10; 32AM,NJ(West Star Environmental, Inc. "" j'"" ""y'y""--N o. 8964' P. 3 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 00 <br /> OA0010 0�W7' <br /> ME <br /> Oy ER I OPERATOR \ CHECK if BILLINg <br /> FACILITY NAMEC' j /� <IT <br /> w i <br /> SITE ADDRESS (} <br /> streetNumbcr irecuort <br /> Street N e city i Code <br /> How or MAILING ADDRESS (if plffarent from Site Address) <br /> Street Number Street Name <br /> STATE ZJP <br /> CrTY <br /> P}IONE#7 &T- APN# LAND USE APPLICATION# <br /> tk <br /> PHONE#2 Exr BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> _ (� CHECK It BI�t INc3 ADDRE <br /> REQUESTOR <br /> BUSINESS NAME Z� l <br /> FAx <br /> Howor M LING ADDRESS 10 <br /> Li L <br /> 1f+1 I V STATE C419 7JP <br /> CITY <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL REALTI;DupARTNe.NT 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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> CouNTx ordinance Codes,Standards,STATE a�RAr,laws. V j� !� <br /> c OATE?'� I •ct <br /> APPLICANT'S SI.GNATURE -- I�7 <br /> PROPERTY/BUSINESS OwNEA(( OPERATOR/MANAGER U ..rrIER AUTHORIZED AGENT 13 <br /> IfAPPI.ICANT is not the BILLING PARTY.proof of authorization to sign Ps required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, 1,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 COUNE'Y 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 REOUESTED: <br /> eowINENTs: 1 �act c�a 1 y COU8 <br /> ,,tUL <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> EMPLOYEE#: DATE: <br /> ACCF_PTED BY: <br /> <:MPLOYEE#: DATE: <br /> ASSIGNED TO: <br /> Date Service Completed (if already completed <br /> SERVICE CODE: C P I E: <br /> Fee Amount: Amount Paid �� �� Payment Date C -L <br /> Payment Type_ L, <br /> Invoice# �( Check# Received By: <br /> ° SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />