Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HFALTit DrPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> .6r� s�z. -t _ 5 R m0 8 C0 1 C0 3 <br /> OWNER/OPERATOR <br /> �---b ` 7-( P,-fv Cut uf, 3� t ��Ma_�M Cx�l<if L!N DDR�ss � f <br /> FACILITY NAME PC -0,� <br /> SITE ADDRESS '�j - Ct..;,� S-F-• CLt Q,,,1 Ac 3 to i <br /> Street NumberDire p <br /> HOME or MAILING <br /> �ADDRESS (if Different from Site Address()/-►// <br /> 3 y '- 1 C"6 N dy �VV Street Number <br /> streetName <br /> CITYSTAT Zip <br /> ��rYzo �-f-- C_ -� 9 4 5 3 <br /> PHONE#t EXT APN# LAND USE APPLICATION# <br /> ( ALV S S'YLt�y1-- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR / SERVICE .REQUESTOR <br /> REGIUESTOR <br /> CHECK If MILLING AODRE5511 <br /> BUSINESS NAME PHONE# ExT. t <br /> YIt <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 DiFAR:I-MENT hourly charges associated with this prnject <br /> or 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 perforated will be done in accordance with all SAN JOAQIIIN <br /> COUNTY Ordinance Codes, Slandards,,;3'FAT1-._jtnd FEDERAL,laws. <br /> APPLICANT'S SIGNATURDA rr.; L �-��—c t l �� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED Ar,E.NT❑ <br /> IfAPPLIC'ANT is not the BILLING PART)',proof of authorization to sign is required Title _ <br /> AVIFHORIZATION 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 assestirnent <br /> information t0 the SAN JOAQUIN COUNIY ENVIRCINMENI•AL HEALTii DF.PARTMF.,N"C as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> M <br /> ,SAN do c'L� <br /> y�TIr,RQN th,Co <br /> ACCEPTED BY: r��,v� �` EMPLOYEE#: E�C J `q Z DATE: i.Z <br /> ASSIGNED TO: 2 U ✓f EMPLOYEE#: DATE: / <br /> Date Service Completed (if already completed): SERVICE CODE: 02- P/E: t1.1;' <br /> Fee Amount: ; Amount Paid �5� �j Payment Date J 20 22 <br /> Payment Type Invoice# Check# �'I S 7"� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rouj <br /> REVISED 11/17/2003 <br />