Laserfiche WebLink
SAN JOAQUIN vOUNTY ENVIRONMENTAL HEALTH DErmRTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />-e— 00-1617.01- <br />AlivNER, OPERATOR ..„., <br />-id bi ov\ (,,(fc utv ck ,„0\ A , 0 (N, L) Et ( ( CHECK if BILLING ADDRESS <br />FACILITY NAME <br />-TT( 0\-3,5 .t63•1 1•\sci-AcYr)ri <br />SITE ADDRESS n n . Street Number Direction 0 t\I \ 0 tu "----.17Namf613CASACYA C Aitv 95aID ( <br />Nola or MAID G ADDRESS (If Different fro,T Site Address) <br />4 10 0 l'j 1-1 W'-4 9 1 i* 1 It—rkt Number Street Name <br />CITY STATE ZIP <br />PHONE rl Err. <br />( ) <br />APN # LAND USE APPLICATIOR # <br />PHONE 22 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />4.EQUESTOR <br />\ \i') \ OV\ C) CCC uc.,,,- (-,, L ( , ),„ <br />....-..._,, ,-....._, , , _ 0( C C\ CHECK if BILLING ADDRESS <br />BUSIS NAM ''.---) PHONE <br />(2 <br />EXT. Nck <br />1 L_1 a ‘ CAL VI C N W \ CWA a ,5 <br />Hora_or WILING ADDRESS , ,03 ci A \ \-1-1 \ q ) uo 1\./ -‘,4 Fax # <br />( ) <br />CITS c) ( l%.\--(3\c\ C AV IS".2 ) a STATE ZIP <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 Of <br />activity will be billed to me or my business as identified on this form. <br />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 TATE an FEDERAL a s. <br />\ DATE:-1 <br />PROPERTY / BUSINESS OWNER 0 OPERATOR! MANAGER OL./ OTHER AUTHORIZED AGENT 0 <br />If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: <br />R:FjlifilUAlk" ir <br />COMMENTS: / Vet) <br />JUL , 0 <br />2018 SAA/ JO A <br />Vii?1C? (11N CO /VAL r Oivw. UA/r ),, <br />N °EPA NrAL <br />/v7 <br />ACCEPTED BY: 1,.1 ., MA) v \i„ t ) EMPLOYEE #: DATE: 1.....W A <br />ASSIGNED TO: \I V e Y)V1/4".." EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: -7 PIE: 1(103 <br />Fee Amount: i C,-) 7 07) Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />APPLICANT'S SIGNATURE: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08