Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACMY ID# SERVICE REQUEST# <br /> it'd PietLc Cq <br /> JU <br /> OWNER/OPERATOR <br /> Cebu if 6lllttG ADORE55 <br /> FACMrNAIff �CFILON C3-0(_.F CfJU f2 S C <br /> SREADORESS 17OS( �SCRLUJl1 QC(.c_drA (2 C-Sc. ��J_•� 4S320 <br /> sa.0 Num oa.rno� code <br /> Ho1E or MA&#ttt ADDRESS (11 D7tteteld from sMeMbws) <br /> CRY N W A2\L STATE C _ KF��0 <br /> PHM#1 En. APN f LAND UsE APPLICAPON# <br /> (2 ,9 ) _ 27-7 <br /> PWK#2 IBM BOS DLSTWGr LOCATKM CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> RELIUESTtt jI-(7t S i.y(Z CTeEctc if Ba.LtNG Atttta66 <br /> BumtEss NAME C{}(p f\3 (�JrQZ <br /> <�Q SC PItDIE# e <br /> aq S -77 am <br /> Homr or MmuNG ADDRESS 'Aalv".4e a-3 G bmx-) FAX# <br /> l ) <br /> CRY STATE Zr <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or basiaen owner, operator or anthoriud agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that I have prepared this application and that the work to be performed will be dome in accordance with all SAN JoAQt,m <br /> COUNTY Ordinance Codes,Srandards,STATE and FEDERAL laws, (� <br /> APPLICANT'S SIGNATURE: DATE: v!t 3 2 C5 i <br /> PRoPErrrvlBusivEssOWNER9 OPERATOR/MANAGERO OtuKRAmaoaRmAGENr❑ <br /> YAPPLictmTis not dwBIIJJNGPARrr.proof ofaaUrar$adon to sign is regained Titre <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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 JOAQum COUNTY ENvutoNmENTAL HEALTH DEPARTMENT as soon as it is available and at the sante time it is <br /> provided to me or my representative. <br /> TYPE of SERvtcE REQuEsTED: <br /> CDMtENM (y� 5rG m.c9 R t x-,i5SU rq . <br /> C-eq— pe Wei c�s�Q� # i2375S 2 9( <br /> ACCEPTED BY: EU1nJDYEE#: DATE: <br /> ASSIGNED To: 6va4a— EMPLOYEE#: DATE: <br /> Date Service CantlIN411aYaaMcorrplahtd): SEWICE CODE: ; ] PIE. C60 `?_ <br /> Fee Amount: Amount Paid I SZ Payment Date i '13 2 <br /> Payment Type L Invoice# 2 9 D Received BY: <br /> EHD 48-02-025 /J SR FORM(Go1Cen Rod) <br /> REVISED 91117/2003 <br />