Laserfiche WebLink
SAN JOAQU BOUNTY ENVIRONMENTAL HEALT- DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />f/ /G ;*° m :1fir AV4- <br />3 23 b <br />�e�s�. <br />ve�;Z <br />OWNER I OPERATOR <br />CHECK If <br />e i <br />(/ <br />BILLINGADDRESSE] <br />/ {A /.1/t. <br />�L/V �� . cy /K U A) � � �� t.✓�S YA-�C-'t' <br />FACIL NAME JD e- YU t �!;,O j / <br />Joe- <br />SITE ADDRESS 4 Do <br />v./ <br />%O LAJt�( <br />STATE w. A <br />ZIP 9—" ^�✓ <br />EMPLOYEE #: 3-Z <br />Street Number <br />Dlractlon <br />Street Name <br />Cit <br />Zip Coda <br />HOME or MAILING ADDRESS (If Different from She Address) <br />CODE: JC 2'Z. <br />Street Number <br />Fee <br />Fee Amount: <br />t [Name <br />CITY <br />STATE ZIP <br />PHONE #t Ear. <br />APN # <br />LAND USE APPLICATION # <br />( ) <br />-232--t&0-0 <br />Received y: <br />PHONEY EM. <br />BOB DISTRICT <br />LOCATION CODE <br />( ) <br />6- <br />3 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />� <br />f \ <br />J <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />4 <br />� 1� <br />�e�s�. <br />PHONE <br />ExT <br />f t 40 <br />HOME Or MAILING ADDRESS <br />[� 7s <br />J Wt <br />�,�jg g�J <br />IIS` :J/!'Cl`C/ c�� <br />FAX# <br />( 0) <br />/p.� <br />ZZ -1 azl <br />CITY e 9 -„ , / <br />ACCEPTED BY: <br />STATE w. A <br />ZIP 9—" ^�✓ <br />O L <br />CKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />I be billed to me or my business as identified on this form. <br />that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />�*ce Codes, Standards, STATT408-9EDER" laws. <br />APPLICATURE: Gt . DATE: <br />PROPERTY / IMNERM ERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />llf.APPLICANTis no✓t BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO REL1201 SE 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 envirorlmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT aS soon as it is available and at the samt.•y.. . . T <br />provided to me or my representative. G (�L� <br />E ,¢_� / �e,a t p0 E(, PLA�,J 4r44 ��ik�FL\Yet tEtNED <br />TYPE OF SERVICE REQUESTED: V&a 6 QPA <br />a rA^165 <br />C/JOMMENNTSS:,,y� <br />(C�`l•I +-� <br />tl i�}Li2EC <br />Ga..t `i u�a.��. tt <br />'7% C16 tL0JtJf—e SAENVIRON <br />qf; <br />ell <I l{F1tl.TN DE <br />�L"k""4F}TE Flow ccl,�L 06L t4l uti 5 BE <br />f, w, e u5 r4y FitetlAf <br />Ve)ii) w t <br />4 Cc>Nc-¢�erC .4.-(D cC" 6-dZL'i.i& U t 6 Vb4 i J k�Lt�:S . <br />ACCEPTED BY: <br />ULt V.E L <br />EMPLOYEE #: 3-Z <br />DATE: Q <br />� <br />ASSIGNED TO: <br />EMPLOYEE M (� <br />DATE: 3 <br />tv <br />Date Service Completed (If already completed):SERVICE <br />CODE: JC 2'Z. <br />PIE: (o't7 2 - <br />Fee <br />Fee Amount: <br />a --LD— <br />Amount Paid a <br />4-7 <br />Payment Date at0 <br />Payment Type <br />V <br />I Invoice # <br />Check # <br />Received y: <br />EHD 48-02-025 <br />REVISED 11/1712003 <br />SR FORM (Golden Rod) <br />2009 <br />OOUNN <br />009AALNT <br />