Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
AN JOAQUIN CO IT ONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />DATE: 114.bt- it) APPLICANT'S SIGNATURE: <br />PA TYPE OF SERVICE REQUESTED: Pleg y, Cheel <br />ACCEPTED BY: <br />ASSIGNED TO: <br />z., <br />1D A <br />1111111111Mir <br />Type of Business or Property <br />Nvwol Wowte, i 0.{;c1.ceA <br />- <br />FACILITY ID # SERVICE REQUEST # <br />SPOO<Zigt <br />ER / OPERATOR <br />NIA1Alte' tilawyn)1 PA(11-- CHECK It BILLING ADDRESS <br />NAME <br />14 <br />SRE ADDRE <br />1to To <br />C, <br />Street Number Direction lbfiCkjiArV241relltie 1.4A'N2.40 Cita ISO Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Cur STATE ZIP <br />PHONE #1 Err. <br />( ) <br />ARM # <br />061°307 1 <br />LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />SOS DISTRICT, LOCATION CODE <br />GI fe <br />CONTRACTOR / SERVICE REQUESTOR <br />REQDESTOR IN 01 Ay AA II.. A A ir coy) IA. 2:( lite II 41\ c IN <br />°LT') i <br />(taw cH.KifB.L.N. moms <br />BUSINESS NAME V Ext pi <br />cr 405 440 1,514 cm) <br />HOME or MAILING ADDRESS 51..51, V11270AZ pit, s tk <br />i <br />FAx# <br />Crrr <br />54)&1-0 YA <br />STATE pia.. 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 DEPARTMENT hourly chares 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 JOAQUIN <br />COUNTY Ordinance Codes, Standards, TE and FED S. <br />evA2A z *Co% Kear( <br />PROPERTY / BUSINESS OWNERO OPERATOR / MANAGER El OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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 COUNT'Y ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />COMMENTS: <br />eivilotered ‘,19110 cliktiVit • <br />Date Service Completed Of already completed): <br />q-vo <br />Payment Type 0 M Invoice It <br />END 48-02-025 <br />REVISED 1111712003 <br />Fee Amount: 1 Amount Paid <br />"?"- <br />Title <br />7.,7pezsry!ser -7mereFr• <br />Ceive <br />SERVICE CODE: gala <br />Payment Date <br />31,51Lez-f I <br />SAN joA <br />ENt4 /4 RO/VmE •E41.TtgotiLiii. <br />DATE 11//2 <br />Dm: 14 12/ <br />PIE: <br />1-11/12-i <br />Received By: <br />'APR n „ 1 2021 <br />SR FORM (Golden Rod) <br />EMPLOYEE #: <br />EMPLOYEE #: