Laserfiche WebLink
JUfv 11 Zoos <br /> ENVIRONMENT FIEALT JOAQUINCOUNTY ENVIRONMENTALHEALTH DFPARTIVLENT <br /> PERMIT/SERVICES SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> .-7 & 2- 1? 753 y <br /> OWNER/OPERATOR ,CHECK If HCl <br /> FACUTY NAME <br /> SITE AD ESS <br /> Shoot Nu ber Dim t` WA J'fl+"' me <br /> NO Or MAILING ADDRESS (If Different from Site Addreas) <br /> 5tmnt NumenrStmot NIMO <br /> CIN STATE ZIP <br /> PHONE#1 Er, APN# ;808 <br /> USE APPLICATION 14 <br /> (?:4) - 0D l f - 030-07 <br /> VHDNF 2 Exr. DISTRICT LocAnpN CDDE <br /> 1 I / <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REaucsTOR CHECK If BILLING ADOAE55 <br /> BUSINESSNAME ° PM # 6 , 7 E><r. <br /> le I <br /> Homegr AILI ADDR SS F # <br /> ��,_ ( X67 <br /> CITY SYATE ZIP <br /> Isii..LIN ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of Salve, <br /> ackltowlcdgc Lhat all site and/or project Specific F.NVIRONNTENTAL HrakLTH DEPARTMENT hourly chargos associated with this prciJect <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.IOAC!uIN <br /> COUNTY Ordinance Code3,Standari, STAT d FEDERAL laws. <br /> APPL,ICANT"SSIGNATURE <br /> NRpPRRTV/BUSIN'E.4s OWNERM OrtLRATOR/NIANAGElk L_I- DTIiER i�U'1'nOR17.RD AGIA-li' \I• <br /> IfAPPLICANT IS not the/J_.g,,&i P11R7T proof of authorization to sign is required hap <br /> 7rep LEASE INF RMATION: Whenapplicable,I,the owner or operator of the property located at the <br /> 0P <br /> authorize the release of any and all results, geotechnical data and/or cnvironmontal�ssjAfVFe11e ( <br /> fD IN COW7 ENvIRONMENTAI..HZALT14 DEPARTMENT RS SOM W it iE available and at vor my nhatiye. /J ,� /J TYPE OF REQUErL>F-C F(C-4-LLTi7/ /�i`'OD�C/—,y�7'�t-e'^� G{-E dUN 1 1 .20 9 <br /> COMMEN -jrI�L 1- 1211k IZ-�I Main 1;#1 6,31key u-7/ V tl e !SP-L J#Wllt� SAN JOAQUIN CO NTY <br /> , prt,�� EN IRONM NT <br /> SkK 0 Woo Do rmff OdLjAe C�nfi'rm�{i(ti1� <br /> 4'14W 30,32.t\. x Ck. Orjf4r <br /> .ACCEPTED?Y: EMP,CYec 4t: 0 3 Z� DATE: -f f (J <br /> O C-t L/ef 02 9 <br /> ASSICNED TO: P. p p4� 6MPLDYEE#: (P Z{3 DnrE: (e �� Mgr 1 <br /> Date Service Completed (!f already completed): SERVICE CODE: S'Z Z P I E' Z <br /> Fee Amount: D Amount Paid pm — Payment Data101\I lock <br /> Payment Type cla yK Invoice# eCff cam— Received By: <br /> EHD 40-02-025 SR FORM(GoldenlRod) <br /> REVISED 111172003 <br />