Laserfiche WebLink
SERVICE REQUEST <br /> Type of BUSIOeSS or Pfoporty FACILITY 10 p SERVICE REQUEST p <br /> Sf <br /> OWNER PERATOR <br /> - i'> CRECKIf 64LLINGADURE55 `" <br /> FACILITY NAME t .0 •.C( C. �f ^GT`t �P�- �... �- L <br /> SITODrRESS 1 i �j WE'h �c.C R�, I-Aen D VJ W(X)� c t' C) <br /> !! 50,011Nmnber loon Slrodt Nuna CH ZY Coda <br /> HOME or MAILING ADDRESS ill Different from Site Addross) <br /> atrtgl Number street NNnat <br /> CITY STATE ZIP <br /> PHONE VII EA t. APN 0 LAND USE APPLICATION M <br /> Qcq) 3) 51 4 016__q60_3& <br /> _DSI("I <br /> PHONE/2 ltT. 1305 DISTRICT LOCATION COUE <br /> qC-)q-2 s (e /C i I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ry G� t����, � ,1 h ��P�� �I < CNECKItBItuNOADDREBsI�` <br /> D r Y <br /> BUSINESS NAME ' ` ( 1 / PNOKEN E'r <br /> HOME or MAILING ADDRESS FAx M <br /> 1�r AC <br /> CITY STATE zip <br /> BILLING ACKNOWLEDGEMENT: 1. the undersigned property or business owner, operator or authorized agent of some, <br /> acknowledge that all site andfof project speclk 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 prepay this p plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes. Stan Ers ST and FEDERAL laws. �j <br /> APPLICANT'S SIGNATURE: �..- -/ DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER W OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT)S n0f the BR(IN,PARTY, proof of authorizafion to sign Is required r irtr <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the abo `w <br /> site addross, hereby authorize the release of any and all results, gootachnical data and/or envirenmentaVsile assessment information <br /> tO thU SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time It Is provided t0 me Or <br /> my representative. �1 <br /> TYPE OF SERVICE REQUESTED: W r/I�f' UuI�GI'b o/�/ r r <br /> COMMENTS: "Le / <br /> �fvr <br /> Chcgt OF 0L))(1e(L-* AUG 16 9/0 <br /> 3-TEMP THERMOLABEL(i, 8qN✓O 42O`/ <br /> Square turns uc` y HFA jy"10 M�COLNl <br /> black as ■ 170•F r�,1 OFPq RN A( V <br /> temperature <br /> ACCEPTED BY: j it (` s reached ❑a*,.ROYEE DATE: <br /> V I J arc <br /> ASSIGNED T0: 1 DATE: V �� <br /> Date Service Completed (if already complated): SERVICE CODE: <br /> Fee Amount: Amount Paid/-/"�sa (J� Payment Date <br /> Payment Typo %s4_ Involcett Check# /2g 0/6(, Received By: <br /> CLrn Ao n' MC V 5 ZB`V ' eD 17^01.1 rr.,u..n D'A. <br />