Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />e-00 f50'\ <br />OWNER / OPERATOR ' <br />Mia f COd D6 vc <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS <br />c2 ' 4 018 Street Number Direction Z.c../.1er, 4 vc et Name --5-71oct e ig, v-, <br />City <br />'I 5Z c/ <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # <br />086 2 06 Z— C? <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT .1 LOCATION CODE <br />clq <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME i i I <br />\JOE <br /> <br />1iEaLpf C0/4 Cre- 7e.(0 4 1 <br />PHONE # <br />( &Ai ) <br />EXT. <br />52/ - go 86 <br />HOME or MAILING ADDRESS 01-ce 5 5:5" s . 04; iti,e-: 1( .)‘11 y <br />FAX # <br />( ) PAYMENT <br />CITY ,4,700m, _ TA, /41 , l'd • ?53 3 7 STATE ZIP RECEIVE{ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorizenU 2f2i, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associtki 366.iiii416-86itry <br />or activity will be billed to me or my business as identified on this form. ENVIRONMENTAL <br />I also certify that I have prepared this application and that the work to be serformed will be done in accordance WW"VATIORATQTT <br />COUNTY Ordinance Codes, Standards, STATE and FEDE L la <br />APPLICANT'S SIGNATURE: DATE: 4/^ 2 - <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TypEoFsERvicEREQuEsTED: As,5-t v4 ,91 rieteiw+fri;r15 i (' r,e14 sepiR (410 be pi4Led 0,- popefi-/ <br />COMMENTS: pct_,F,„51(4-4 )4?.1Lit.3 ir.2): resicience 400 ccover4 il, 5 it roy Ropusrcir) re,,c4 ;yte, <br />L. loccio-oro 100 tsc-)al liPe F t!' Ejelif°, C)''' . ILA' 17 ottv-'rctenvire oireC1, Vel ;Cy i f sepitt. tor k 4 v4 q-) Yr\ i <br /> <br />...) rtl cik I-bet-A-it:int' a lorrauetai 0 , e s, 4../c rCi &lin e ri .„)O apj- Se2+ bgick cc 1 e, <br />ii leCJ WI I"' . ' <br />be mei. irhinieci <br />, <br /> -lb .,^)el is - CALL (209) 953-7697 <br />FOR INSPECTION. • , <br />ACCEPTED BY: ..-- 2, . . . . L . . . . - 48 HOUR NOTICE EMPLOYEE #: DATE: til3 p1 <br />REQUIRED. ASSIGNED TO: AJ A EMPLOYEE #: DATE: LI idp 7 <br />Date Service Completed (if already completed): SERVICE CODE: 0 (, ) P/ E. 93 0 -,i, <br />Fee Amount: 4 ) S-c9- Amount Paid i cz Payment Date <br />Payment Type Do ,L.- Invoice # ele1#If3072_ Received By: „.,/.. <br />Title <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)