Laserfiche WebLink
RE TOR CHECK if BILLING ADDRESS': <br />PHONE # <br />4zi7d9 ) c59-33 /7. <br />--kr--c1C)° 11 <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />cKLO 5 ci q 0 <br />OWNER / OPE OR <br />A) it- og-i44ce. m 41,-)14. <br />CHECK If BILLING ADDRESS <br />FACILITYZUc <br />SITE Arp roc <br />Ld.qtreet Number Direction L714 AV:1t ) PD ?)Of <br />Zip Cod cri(zeb <br />City <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY <br />54.771 6---- ZIP STATE <br />PWNE,11 EXT. <br />c109) 9.s-7 s—c.024 <br />APN # u-72- -tic_ c..,4 LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />— <br />LOCATT CODE <br />CONTRACTOR / SERVICE REQUE <br />e? V •gA L <br />HOME AILING ADDRESS /0'7 <br />°F4-°17 9 C 2 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, STA and FEDERAL la <br />Fet"ittlt 3ettir <br />CITY STATE ZIP <br />APPLICANT'S SIGNATURE: <br />PROPERTY/ BUSINESS OWNER El PERATOR / MANAGER 0 OTHER AuTriORIzED AGENT <br />DATE: <br />If APPLICANT is not the BILLING PAR77, proof of authorization to sign is required Tit le <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 environmentaUsite 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 />TYPE OF SERVICE REQUESTED: <br />NI- <br />COMMENTS: BEG°V <br />ti 4 '1-sb <br />30 ' <br />GOOW pl.. sal 30 ,,titOsil <br />EIVIROINI3p8WEt* <br />ACCEPTED BY: 0 L I L,, E t 0-4- EMPLOYEE #: c 3 2_ ( DATE: <br />ASSIGNED TO: CA 4 „Ic...t E- ...c". C-/..) EMPLOYEE #: C.) t4 L.,--7 DATE: c., 4 I 0 g. <br />Date Service Completed (if already completed): SERNIICE CODE: oc, / PIE: <br />Fee Amount:0 9 ,t, .t -.)...T., Amount Paid 15 / F. b b Payment Date II <br />Payment Payment Type t./ <br />Invoice # Check # p.31 if e Received By: -10/1__ <br />SR FORM (Golden Rod) <br />EHD 48-02-025 <br />REVISED 11/17/2003