Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 2� D <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 16N u 23 ko c3a COT?- <br /> OWNER/OPERATOR (� �:� � � <br /> w CHECK If BILLING ADDRESS <br /> FACILITY NAME CA <br /> !e,Z4'1 /n ,n'6 �' Til <br /> SITE ADDRESS 2.5� l.l'A `rU `I �1 j'e\� ^ I^'_ Ll S-2,0-1 <br /> Street Number Direction treet Name �T K�Cit' ZJI Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> r''� Street Number �J�I Street rNatme W <br /> CITY �'.(��rA ,- \ STATE I�/t ZIP <br /> PRUNE#1 v ' \) EXT APN# LAND USE APPLICATION <br /> (I1) '2N(- <br /> PHONE#2 EXT. BOIS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 0 On <br /> `,„ ^ ` ' <br /> v/�`'r//`v ` �-. I1 ,/Y /A (y��l/1/1 pa 1^ �/1 /f C <br /> HECK If/BILLING ASD 7DRESS <br /> BUSINESS NAME ' 1 /�/1)n//,n`1 eA�A�/t t `� \�I lv/r�Y L✓�r t�ll��L, PHN) Em <br /> HOME Or MAILING ADORES ^ \ ( (,,,, r�.I f�✓G./ FA%# <br /> 1 V n4r1V (��1 <br /> C I <br /> CITY STAT ZIP <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 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 1 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.-74 �r <br /> APPLICANT'S SIGNATURE: 004' P /�Fy�`7��— DATE' L2v _ <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER jd OTHER AUTHORIZED AGENT If <br /> /fAPPL/CA' ? not the BILLING PARTY probf ofvauthorization to sign is 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 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 /> e�,-�r^ P <br /> TYPE OF SERVICE REQUESTED: i�rt\/rV o 2COVA U, F '15��J„C' I REC <br /> COMMENTS: 1 ^V co .J� Yl / 1 ��LJ`l�� `l{�I��r 0 1 11Z <br /> FtgN JO 20T� <br /> ENVIgQUIN CO <br /> UIV <br /> HEALTH pE M NT <br /> ACCEPTED BY: WAO EMPLOYEE#: DATE: Mp /N -q D <br /> ASSIGNED TO: �j _ cWNV\- EMPLOYEE#: DATE: V 6 V <br /> Date Service Completed (if already completed): SERVICE CODE: ��I PIE: <br /> Fee Amount: 1 - Amount Paid �t�a Payment Date <br /> i <br /> Payment Type Invoice# Check# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />