|
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT
<br />SERVICE REQUEST
<br />Type of Business or Property
<br />(A) et i-ti
<br />FACILITY ID #
<br />PADO b '9,-1 q, k
<br />SERVICE REQUEST #
<br />.-_-=/2_60 c",
<br />OWNER,/ OPERATO )
<br />CHECK if BILLING ADDRESS El
<br />/.:1:2-t,:',.' '-c...
<br />FACILIP( NAME
<br />f,,,
<br />i ',Icy, C .41
<br />SITE ADDRESS SITE
<br />Cep 3S Street Number Direction Al, 101 - I il e rc ,i), ( ' S reet Name City Zip Code
<br />HOME or MAILING ADDRESS (If Different from Site Address)
<br />Street Number Street Name
<br />CITY STATE ZIP
<br />PHONE #1 E
<br />( )
<br />APN #
<br />Oil— ---L‘ Ci
<br />LAND USE APPLICATION #
<br />PHONE #2 EXT. BOS DISTRICT LOCATION CODE
<br />CONTRACTOR / SERVICE RE UESTOR
<br />REQUESTOR
<br />...-..eit•-\..a.i." i/VIAA-01-N CHECK if BILLING ADDRESS
<br />BUSINESS NAME L.. I,/ 1
<br />P ut (:' If 5 POol Picts, t_ efirry
<br />PHONE #
<br />( ZC) (1 ) C'S a — g'- LI 3
<br />EXT.
<br />HOME or MAILING ADDRESS
<br />(a0(...1 A, hi -L: 0 i t ( je— 111
<br />FAX #
<br />( )
<br />cn-y B is (),. STATE.,,,, L....
<br />ZIP cf 5_26 6
<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 FE ERAL laws.
<br />APPLICANT'S SIGNATURE: DATE: 2/V 1‘i
<br />PROPERTY / BUSINESS OWNER CI
<br />OPERATOR / MANAGER 0
<br />
<br />OTHER AUTHORIZED AGENT 121
<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 a)ihe same time it is
<br />rovided to me or my representative. -
<br />ilr%zzi'klikf7., TYPE OF SERVICE REQUESTED: Folt Et, ..9,..4 rci.3A-c3ci.c..1
<br />COMMENTS:
<br />g
<br />' 4o,,, (.11,1
<br /> e
<br />S4 A , 0 e ,
<br />i iv
<br />li? I „, .
<br />
<br />,v/11, i.).- ,..civr.
<br />\
<br />1A9CfewEPTED BY: I .4--, ,,,/.....t......
<br />
<br />DATE: 2_/6, // cc.
<br />
<br />EMPLOYEE #: 2 c 7 o
<br />0J (..k_ / , tvla./, .
<br />EMPLOYEE #: 93 k, ---z_ DATE:
<br />i%•"4 i I I 'ill A
<br />llaqf S 511)04) ,11P1 II) eted (if already completed): SERVICE CODE: C 7_ 2 _ P/ E: 3 6 0 2._
<br />414;gli
<br />Fee Aurmo Amount Paid , Payment Date 2/7. Li.
<br />Payment Type 1. Invoice # Check # 7/ , ,,_,.i Received By:
<br />Title
<br />4
<br />END 48-02-025
<br /> SR FORM (Golden Rod)
<br />REVISED 11/17/2003
|