Laserfiche WebLink
JAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />T' <br />SERVICE REQUEST # <br />FAx# <br />( ) <br />X30 � <br />S�5 saa <br />OWNER I OPERATOR <br />–Fp– A C y =F'l I <br />IV <br />CHECK If BILLING ADDRESS <br />FACILITY NAME �n �v �N N <br />/ <br />SAN <br />SITE ADDRESS ��. W <br />' I rte- 5T <br />1 RACY 95374 <br />Street Number Direction <br />Street Name <br />city Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />DATE: 3 ( /(o / po <br />ASSIGNED TO: <br />��.'Z <br />Street Number <br />DATE: -311(4(0 <br />Street Name <br />CITY <br />SERVICE CODE: <br />STATE ZIP <br />PHONE #f EXT. <br />APN # <br />Z3 D (J7 <br />LAND USE APPLICATION # <br />( ) <br />2-35 - °S-5 -(6 <br />((.J ( p <br />PHONE #2 ET. <br />✓ <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />Received By. <br />S <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR bt .J <br />Q6 U A O 0 L L 5 o,+ =IJ C' Alluvia (/ Y CHECK If BILLING ADDRESS <br />•j— l \t`PHOHONEE# <br />BUSINESS NAME <br />III MOFF47- 010. <br />T' <br />HOME or MAILING ADDRESS <br />FAx# <br />( ) <br />CITY 14 'r–F' C,1 A.- STATE CA ZIP 9 533-C <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific 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 prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDE laws. <br />APPLICANT'S SIGNATURE: , H c n E: o3-1,6-10 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR / MANAGER ❑ HER AUTHORIZED AGENT® frr/EN� <br />If APPLICANT is. not the BlLLiNG PARTY proof of authorization to sign is required Title <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 />infor[nation 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 />TYPEOF SERVICE REQUESTED: ;000c sAi rw Tti 41e.-tOD£.L-. IAL_s4-.J CpEGI[ <br />COMMENTS: <br />-Pt,v L 12 E 1�1OD EC, <br />DD �/ <br />PAYMENT <br />RECEIVED <br />16 2010 <br />DMAR <br />SAN <br />NVIRONMENTAL <br />EPARTMENT <br />ACCEPTED BY: <br />b C_L O & L <br />EMPLOYEE M C) 2_ <br />DATE: 3 ( /(o / po <br />ASSIGNED TO: <br />��.'Z <br />EMPLOYEE #: 2 13 <br />DATE: -311(4(0 <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />PIE: 3 G 2— <br />Fee Amount: <br />Z3 D (J7 <br />Amount Paid <br />i -3r). C 7 <br />Payment Date <br />((.J ( p <br />Payment Type <br />✓ <br />Invoice # <br />Check # 47EZ. <br />Received By. <br />EHD 48-02-025 ' .SI OT M (i3Olifdn Rod) ' <br />REVISED 11/17/2003 <br />