Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />SV-0 0 'zvz -1--\ <br />OWNER! OPERATOR <br />C-_,:17-7 C___HDI1 K4J--- i '1.1-\ & i Rd\ld\ -I, ( I-fd t AA H.Ds N-L i 1 LL C, CHECK if BILLING AD DRESS <br />FACILITY_ NAME <br />c t. <br />, . <br />(:".•?,c,i --k -Df cZe .(7; on& ( Ez..l, \e.61 ksT e 1 enn kk-z-:., ott i <br />SITE ADDRESS <br />Co -0 9 Street Number <br />— <br />Direction Street Name <br />c•---_- <br />71-6 C (Cfil) City <br />61E21) 7._ <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Crry STATE ZIP <br />PHONE #1 EXT. <br />(29) (etI1 — 249 O <br />APN # LAND USE APPLICATION # <br />PHONE #2 Ex-r. <br />( ) <br />BOB DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUE§TOR <br />R ACk‘\st_r- cl \ CrTyt j\ I C.....ri CHECK if BILLING ADDRESS <br />- Busittps NAME , <br /><1_. i RIC f\ei 6 i ti-i-a--1;eAk 1-6 i-i-,t, i <br />PHONE # <br />( zol) <br />EXT . <br />,---- - HomE or MAILiN A DDKR2S Cr' i <br /> <br />(..'a'1 E. Mn>e)1 t cc, Zt V--c.e.71- <br />FAX # <br />(21D9 ) 681 -- <br />Cny <br /><.t.1) dCf.z)1" STATE (A ZIP eicaz) <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 <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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER <br />OPERATOR / MANAGER 'a OTHER AUTHORIZED AGENT 0 <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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 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 />electronic <br />ACCEPTED BY: Vidal Pedraza EMPLOYEE #: 6213 DATE: 2-8-12 <br />ASSIGNED TO: Dania Afonskaia EMPLOYEE #: DATE: ) -8-1? <br />Date Service Completed (if already completed): SERVICE CODE: 521 P1 E: 1601 <br />Fee Amount: 461 Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />payment confirmation 156253359 SR FORM (Golden Rod) <br />7R6LI S51 <br />DATE: <br />Title