Laserfiche WebLink
SAN JOAQUI.. COUNTY ENVIRONMENTAL HEALTH L._?ARTMENT <br />A SERVICE REQUEST <br />FACILITY ID # I SERVICE REQUEST # Type of Business or Property <br />A MgMgA-fr S <br />OtA:N ' t -OR <br />/9/4 Gild; ' <br />FAt <br /> <br />iTvjE <br /> <br />SITE ADDRESS I A/04 -6 1 Are- ? Str- Number 'Irectiud I <br />.,iLING AnDRES (If Nffer,:zu fron• Site ' <br />SRoo-7210({2 <br />CHECK if BILLING A :)RESS <br />Pr M4Air£ e 5)5 334. ,;„•,,,. <br />F,Ooo io <br />Stre,, N <br />CITY <br />Street Name <br />ZIP <br />USE APPLrATION # APN # PNF Ex, <br />(a4 g 7 5 - 9VO <br />Lo&1- BOS DISTR,CT E• I-IONE '2 EXT <br /> <br />'ONTRACTOR SERVIC1. REQUESTOP. <br /> <br />1-1QUEST <br />—777' ; 5-rc,) Tr1,or" <br />BUSINESS NAME <br /> <br />Po° e <br />HECK If BiLLiwo IL SS <br />PHONE # EXT. <br />(q/,) G3g- -7(6,5 <br />HOME or MAILING ADDRESS <br />/ 1 3693 Ply r) S LA.) 4 y 74/#k G35 - g14 3 <br />CITY 60) gutter c 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 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 applic tion an that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, S AT and FE AL laws. <br /> <br />DATE: <br /> Ci4 <br />PROPERTY /BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHFR AUTHORIZED AGEN1C7'tfl- <br />It APPLICANT is not the BILLING PARTY prouf of authorization to sign is reruired 'Title <br />AU )RI 'ATION TO RELEASE INFORMATION: When applicable, I, the own, or operator of ie roperty located at the abc:e <br />site .,ddres, hereby authorize the release of any and all results, geotechnical data and/or enviro .nentL,l/site lssessment information <br />tu le SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tile same time it iq provids to me Of <br />y representative.i/ <br /> Pe'rair R-emod_ci von Chi CIC TYPE OF SERVICE REQUESTED: <br />SAN .izi,e4 - 9 COMMENTS: <br />fiE-,41';'):14y4t;_c <br />°L1 00,4 ti'vtiiitkiv <br />APPLICANT'S SIGNATURE: <br />DATE: ACCEPTED BY: pi. kLA tMPL .eEE #: <br />ASSIGNED TO: VI CI a ped rin <br />Date Service Co; pleted (/ already co .ipleted): <br />Fee Amount: It 2i.00 Amount Pailgt24 0. 6?) <br />Payment Type Invoice # <br /> <br />I Check # <br />#: DATE: <br />Payment Date <br />P/E 3 v)02, <br />5719*. <br />Received By:[Atipipi--- <br />SERVICE CODE: a S-2 6 <br />EHD 48-02-025 <br />07/17/08 <br />00 <br />SR FORM (Golden Rod) <br />