Laserfiche WebLink
SAN JOAQUI ,OUNTY ENVIRONMENTAL HEALTH D ,RTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />-)f—A)Y1•61'Wl <br />TNER / OPERATOR, '\ <br />c, Li A s A , r. ( ) ( c \ CHECK if BILLING ADDRESS <br />FACILITY NAME <br />\5 Y U o 16.) 1 <br /> <br />SITE ADDRESS <br />17 11 .' - Street Number Direction -).- f .-..)1\1 \ 0 iJ'..-eleTNamS. 0 CAIACYA (-:26 RN, 95a10 k <br />HO i E Of MAILING ADDRESS (If Different from Site Address) <br />ii flui-1 961 ii \ 14t Number Street Name --- T'\ 100 <br />Cry <br /> <br />STAKE ZIP <br />61,Yg )01 \ <br />PHONE #1 Ex-r. <br />( ) <br />APN # I LAND USE APPLICATION? # <br />PHONE t2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />‘`‘\'\7\9'(--')0, _ vG\ <br />‘OS t- P <br /> EXT.BUSIVAMB <br />if BILLI <br />7 <br />NG AD DR <br />. <br />E <br />I <br />SS <br />2 <br />CHE <br />S <br />C <br />- <br />K <br />M 9 -q <br />, <br />H oi..pi- 3,1(,:,7 A D DII,E1SS \ic u.) .\4 q q ...\::.... \77 FAX # <br />( ) <br />CITS C) c .f->-\--()-\-\ C:-/Av 6iS .-.1 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 or <br />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 TATE an FEDERAL S. <br />(1 DATE i I 1 (6 <br />PROPERTY/BUSINESS OWNER D OPERATOR/MANAGER DU OTHER AUTHORIZED AGENT 0 <br />If APPLICANT 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 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 Of <br />my representative. <br />4i VAWE'lle . TYPE OF SERVICE REQUESTED: RPe i' COMMENTS: -11 er) <br /> <br />111t. i il <br />' u <br />'4A/ JOA <br />14 AIVIR Q <br />2018 <br />Z-1/N CO OfVry <br />I DEP IV7-AL <br />AIR riliTgAi , <br />ACCEPTED BY: N o. vy0A/VALif EMPLOYEE #: DATE: <br />ASSIGNED TO: \11 V ekkor p....-- EMPLoYEE#: DATE: 1,1 VI i <br />Date Service Completed (if already completed): SERVICE CODE: P/E: <br />Fee Amount: ‘, c-",-A , 0, Amount Pae /.31.2‘ DD Payment Date <br />Payment Type c- I,:34, , Invoice # Check # Received By:7A_ <br />APPLICANT'S SIGNATURE: <br />Title <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)