Laserfiche WebLink
SAN JOAQUIN 1UNTY ENVIRONMENTAL HEALIT 'F,PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />5 w imrnitir pooL <br />FACILITY ID # <br />._...) o i 7 <br />SERVICE REQUEST # <br />-5A60 .1 " <br />OWNER / OPERATOR i-4-0/4 CHECK if BILLING ADDRESS Erets-713(,JN.) <br />FAcii.rry NAME . . % — ---, _ -a SW / rY7 m iluG, PoOL_ <br />Street Number Direction <br />SITE ADDRESS <br /> <br />Street Name City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />P . O. /3 ((-) 7 9 60 .5-- Street Number Street Name <br />STATE ZIP CITY 5 i___0 c k __no r\J <br />CR 96-7-c- . 7 <br />PHONE #1 Exr. <br />(2.L '1) -177 -1 q Ci Li <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR p 1+1 u_r P D . 1--/ -1- &) 1<.L-E- CHECK if BILLING ADDRESS O <br />BUSINESS NAME pfx-412.4462(AA ,..) POOL- 1 5P14 <br />EXT. PHONE # <br />(.7(2)33(/ 3Y c). <br />- HOME or MAILING ADDRESS Pc , 1,30x 7„ (g.... FAX # <br />( afi),33Y - 603-27 . <br />CITY 1.1U000 82 r L.X-7 STATE CP ZIP <br />*-1zei <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, ST PERAL law <br />DATE: APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER El OPERATOR / MANAGER El OTHER AUTHORIZED AGENT L31 <br />If APPLICANT is not the BILLING 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 />information 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. PAYMENT <br />TYPE OF SERVICE REQUESTED: PO 0 L Re iaici I )2. RECEIVED <br />COMMENTS: FEB 2 0 2004 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />I ' <br />ACCEPTED BY: EMPLOYEE #: W. y Cif <br />. <br />DATE: <br />/ I <br />ASSIGNED TO: _ 6-0 EMPLOYEE #: 0 y L ---) <br />v <br />DATE: r <br />Date Service Comp! (if already completed): <br />;— <br />SERVICE CODE: (.! - ---", PIE: <br />Fee Amount- V )y Amount Paid A t F-4., n-0 Payment Date ?-t2-0f0r <br />Payment Type 1.7.- Invoice # Check # 'in i i Received By: 71 <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003