Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />I/10016V: .‘ u ALIA box <br />FACILITY ID # SERVICE REQUEST # <br />9ZOV-71/4/ <br />OWNER/OPERATOR /Th <br />CHECK if <br />U c k ay n G 0 1/ \--Ligle9,7 <br />BILLING ADDRESS <br />FACILITY NAME • <br />1Y lAil 61112.COS 0 SC OS eSiltb 100211-V lam It <br />SITE ADDRESS ADDRESS <br />1--50 t Street Number <br />5 • <br />Direction S acrit 'It/ vrtz) Si- . <br />Street Name <br />LO 8 i <br />City <br />cis-2 li o <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) N 10 <br />Street Number <br />6 YeeY\V`Mc\ bk <br />Street Name <br />CITY STATE ZIP <br />E) ocy, k o v‘ ca <br />PHONE #1 EXT: <br />(20q 90 9 - 3c1D 4 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR (-) <br />rt. -2q1.-4- <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME N A <br />t`'Antv,cpc.OS 41v,...9,. e_s\.:1,9 Ivlciia‘ \ lv-, <br />P ONE # <br />,()(4 <br />EXT. <br />HOME or MAILING ADDRESS <br />,-31-1r) <br />, <br />C.1 <br />FAX # <br />CITY ,L7-__. .,. oc \.., to y\ r fa <br />STATE ZIP qC5 q05 <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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: ()act% 0 6, ,,,v1.27,11,5 3 DATE: av ( lq <br />PROPERTY! BUSINESS OWNER <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 Pitpd to me or <br />my representative. 4f <br />TYPE OF SERVICE REQUESTED: oat Le Con ut141461 ifr <br />COMMENTS: JUN 1 <br />8114',...10A,, 4 201.9 <br />-c40. •1-04141 ‘,00, <br />Hci.p E-A/7,1ivTy <br />-747- <br />ACCEPTED BY: L.Ct LA r a i EMPLOYEE #: "7 lc x.) DATE:q <br />DATE: <br />(461 <br />(19 ii N <br />P/E: )1 (.06 3 / <br />ASSIGNED TO: <br />CI 1 a 'F) EMPLOYEE #: <br />Date Service Completed (if already completed): SERVICE CODE: (" <br />Fee Amount: ,ti 1 5t; - ' 00 Amount Paid /,5')0 <br />L/ <br />Payment Date <br />Payment Type Ca.6- Invoice # Check # Received By: <br />OPERATOR! MANAGER El OTHER AUTHORIZED AGENT El <br />EI-ID 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)