Laserfiche WebLink
11/30/2004 11:53 2094683433 FIFTH FLOOR PAGE 02 <br /> SAN JOAQUI*OUNTY EN'VIRONMFNTAL HEALTIOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Cas Sidon ZI ®4 � 1Z/O <br /> OWNER/OPERATOR <br /> CHECK f}BRLINa AoDRI;,SS L1 <br /> FAcumNAME l <br /> 1 C.1 v�,�� �j <br /> SITEADDRESS I d3 S Ia..l n J 1 f -e-+ f � lu(*-P-C1 q5 33 <br /> Street Number Dlrecdon Street Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1 02 C Mom-) <br /> Skreet Number J street Name <br /> CITY e- co STATE CCt_ ZIP 5-3. -7 <br /> PHONE 01 EXT. APN# LAND USE APPLICATION# <br /> (30\5--01-79 I <br /> pWONE#Z Err. SOS DISTRICT 7LOC�Cai)E <br /> 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ` <br /> J CN,=CK if 61LI.ING ADbRESs <br /> BUSINESS NAME PHONE FXT• <br /> o <br /> lne Pr .- c.n _ ( L4 _ gcAO <br /> HOME or MAILING ADDRESS FAX <br /> cal C0�!(o-q(p 3 <br /> CITYr�►`^ STAM /�_ ZIP <br /> L— S <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 or <br /> activity will be billed to me or xray business as identified on this form. <br /> 1 also"certify that I have prepared this application and that the work to be peafbnned will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: AAE: 2^ r <br /> PROPERTY J BUSINESS OWNER 11 OPERATOR/MANAGER E3. OTHER AUTHORIZED AGENT W P 2O e Cfi o-c—CA <br /> IfAPPZIC4NT is not theBILLINGPARTY proof of authorxZAtL"[oiT to sign is required Title <br /> AUT110MZA110N TO RELEASE INFORMATION:When applicable,T, 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 environmentaYsite assessment <br /> information to the SAN JoAQUIN COUNTY EwiRoNMENI'AL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. ppt� 11 <br /> TYPE OF SERVICE REQUESTED: O`;C g3Eq#-kt- tVED <br /> COMMENTS: <br /> �EB � p 2005 <br /> sAN joAnu►N GOUNTY <br /> ENS Di PMTMENT <br /> AL <br /> Ham- / <br /> ACCEPTED 6Y: - j�p r- EMPLOYEE 9: (;ga,,qR DATE: <br /> ASSIGNED YO_ Qe 'CL,�y EMPLOYEE#: C�'�C� DATE: <br /> Date Service Completed (if already completed): SERVICE Ct7DE: 161 t2 I <br /> PIE: D <br /> Fee Amount; �,I_-` �Q !amount Paid, �a �-�� Payment Date. <br /> Payment Type L Invoice# Check# `(�3 <3 Received By: <br /> CHD 48-02-025 ,SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />