Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
3S1) A/kkle <br />SAN JOAQ COUNTY ENVIRONMENTAL EALT /EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # ( t_5246/ICE REQUEST # <br />-5 Oa co 5- 4 .C. q <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESSR <br />FACILITY NAME <br />- R-CA VI ot rits WZ!) MI-. <br />SITE ADDRESS 0 , <br />A 0 <br />Street Number <br />L.1 <br />Direction <br />1 tkaAn 5\te-c-A. I Street Name <br />"(k:x.cNO$1‘ <br />City <br />q 5U:4:7 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 Exr. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />ktv•N‘P Kr M.:‘-‘.inu <br />CHECK if BILLING ADDRESS <br />fq: <br />BUSINESS NAME <br />cAkt.kt '5 W:41 R \ ck,..ic.c-vc•-r, .I.Nix.c_. <br />PHONE # <br />( Loq) <br />EXT . <br />sql- <br />HOME or or MAILING ADDRESS <br />bco 1. i - ---csovvka.cs,e__ CNA <br />Fax # <br />(1.0 i ) .9-6 41ç, <br />CITY et61 1.1„ 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 <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: L <br />„Jo <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENTVk <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: ae-E c . 14 G--.4-(--D-t° C 0 --) (4-C79-n-0 <br />COMMENTS: k---.,--rF \\•11- <br />n , f--E,L,--1 S.7F-, nlitot ro !Iv <br />V 0Pli <br />,, - _2 202 ,,,,4„i v <br /> <br />i*if ik C.0041. VAQ r• LAS — N_ -'smeW Iv -,1,,r4 psy <br />ACCEPTED BY: 0 LI, U...A.. (2--At EMPLOYEE #: DATE: <br />ASSIGNED TO: AEA /.......A 2_,A. EMPLOYEE #: DATE: s).--/ <br />Date Service Completed (if already completed): SERVICE CODE: c (. / PIE: 34, (:)._ <br />Fee Amount: q ç' .r-'J Amount Paid -4- I c2.15", L, L, Payment Date <br />a7-11 7--- <br />Payment Type ,- - Invoice # Check # 5 ' d (.c, i Received By: 7/2 <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />-1=105.2_fiq1p WW-PlehnS <br />DATE: IS Z,. rt., <br />iscuse,Ak• <br />Title