Laserfiche WebLink
SERVICE REQUEST <br />Type of Business Or <br />00 1 <br />jBUSINESS NAME i— <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER/ OPERATOR <br />HOME or MAILING ADDRESS <br />_ 1 <br />fl(IUI <br />ctracifBaitNO noDNEss❑ <br />Realty NAME <br />FAX # <br />SITE ADDRESS <br />S1f�tFumber <br />06actlon <br />vv ' <br />j'{1�,� IC, <br />ASSIGNEDTO: A43 qq <br />EMPLOYEE #: Cr( <br />OO <br />Cede <br />Date Service Completed (H already completed): <br />NONE Or IIIAtutIG ADDRESS (B Different Trom Site Address) <br />•T1 I Number <br />G <br />n „ , ^) <br />IL �ITJ't'/561eat 1 <br />CITY <br />/5 -DC) <br />STATE Q ZIP <br />P E q <br />( ) <br />O' I' <br />APN # <br />Check #E,4' 7 SDI <br />LAND USE APPLICATION # <br />PHONE## ET. <br />BOS DISTRICTLOCATION <br />CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Lman C _ .�/�',� L � CHC-atif BIWNG ADDRESS <br />II__' <br />jBUSINESS NAME i— <br />�i C_ .. <br />P <br />HOME or MAILING ADDRESS <br />H gNryo <br />nI <br />/V47 Coo <br />PgRTrq< <br />FAX # <br />CrrTTP <br />STATE ZIP C <br />BILLING AC WLEDGEMENT: 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 <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 performed will be done in accordance with all SAN JoAQtmv <br />COUNTY Ordinance Codes, Standards STATE and FED/E��nL laws. , I •//t /� <br />APPLICANT'S SIGNATURE: I�VZL/'Q WA CZ, DATES: / T�.l 121 1=04 -- <br />PROPERTY <br />tt�./Y�J� �L_^ n <br />PROPERTY/ BUSINESS OWNERO OPERATOR/ MANAGER O OTHER AUTHORIZED AGENThd Fwd , _thy I l_X.Tb <br />IfAPP7iCANTisnot the BrzLaycPARTTproof ofauthorization tosign isrequired 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 />information to the SAN JoAQUIN COUNTY ENVIRONmErITAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. _ PA I <br />TYPE OF SERVICE REQUESTED: <br />F Or - <br />COMMENTS: <br />/U <br />J Ar <br />H gNryo <br />/V47 Coo <br />PgRTrq< <br />ACCEPTED BY:' <br />EMPLOYEE #: (,2JJ <br />DATE: Z.( 2-7- <br />2ASSIGNED <br />ASSIGNEDTO: A43 qq <br />EMPLOYEE #: Cr( <br />OO <br />DATE / IE7- 2 -- <br />Date Service Completed (H already completed): <br />SMMCE CODE: <br />6 <br />PIIE: t G 0Z <br />Fee Amount: I�j <br />Amount Pa <br />/5 -DC) <br />Payment Date 22_ <br />Payment Type _ <br />Invoice # <br />Check #E,4' 7 SDI <br />Received By: <br />EHD <br />REVISED 11/17/2003�iailm 1c-j5� 1�5v I <br />? PSAI 1 I <br />SR FORM (Golden Rod) <br />ry <br />