Laserfiche WebLink
APPLICANT'S SIGNATURE: <br />PROPERTY / BLsINEsS OwNE OPERATott / MANAGER.'iAGER 0 OTHER AUTHORIZED AGENT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />gaS Sig irb A <br />FACILITY ID # <br />F- R o oo L,c) <br />SERVICE <br />iCO3'7441/ <br />REQUEST # <br />OWNER / OPERATOR Cafli Gas R.41r -6 led l• i\JC- CHECK if BILUNG ADDRESS vv i <br />FACILITY NAME CsaAAA,re......q. <br />SITE ADRESS <br />—Nvoc.) Street Number Direction <br />W •zip 1 ‘ Ill S f- Street Name <br /> <br />fl--.(C.... 0%1-A <br /> <br />City -.1 <br />q 63 76 <br />code <br />HOME Or MAILING ADDRESS (If Difterent fro Site Address) <br />G cum e ac 5.11-e recc Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />(5/0‘V eS ti ir (liel <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />(50) 221 — 65i" 11- <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Aiet fa a 4(o bad . I CHECK if BILLING ADDRESS <br />BUSINESS NAME .e._..e..e.441t...Z Oot— 7r40tCy- , PHONE # <br />( 51a 2-8°7 6.8-17- <br />Err. <br />He0456AILIVDDFIEISS4t... ..f... FAX # <br />( ) <br />CrrY Tra c.44 sz:52. ZIP q 5 3 76 <br />BILLING AC WLEDGEMENT: 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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and RAL la -s. <br />APPL1CAYT is not the BILLING PARTY, proof of authorization to sign is required <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 envir nmentaUsite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availabl ptilite same time it is <br />rovided to me or my representative. <br />- v...k7lezi: t <br />TYPE OF SERVICE REQUESTED: CO <D...)..) (--Q. --2.1...z e c._,v,,,,._ Nek , <br />COMMENTS: <br />L. JCIir,. 4 44f ? 2°20 <br />#1441141RarV COu <br />71431 P4t/i/7:4 riVrY <br />c/Vr <br />ACCEPTED BY: .......11/4.,_. te,.. v-\,, 9--.2- <br />EMPLOYEE #: DATE: <br />ASSIGNED TO: .....,.. r\ V--\cv----fi-2 EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 01, I P I E: <br />Fee Amount: k -.. 2 Amount Paid /5-2 .0 2) Payment Date <br />Payment Type c_ c Invoice # Check # n ()111-75-24 .., <br />Received By: <br />hozei <br />Title <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003 ek.I (4, 2_33(r