REMOVAL_2007 - Laserfiche WebLink

Home Browse Search

SAN JOAQU*OUNTY ENVIRONMENTAL HEALTFI&PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER/OPERATOR CHECK if BILLING ADDRESS El FACILITY NAME SS P# t-72- SITE 72SITE ADDRESSP-AtCl-FtG AVG . �1OGkI Of� qS20-7 7 Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (it Different from Site Address) -IMPI l21A-I` '4I G-H W A-Y ` Street Number Street Name CITY STATE Zip 11,0 ro 70 S+ r� rn C, CA- PHONE#1 4PHONE#1 EXT- APN# LAND USE APPLICATION# (%2 ) 1121-&&781 X 9 0 PHONE#2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR C SERVICE REQUESTOR REQUESTOR fkiU 4 I -r-F-S C.0 CHECK if BILLING ADDRESS p BUSINESS NAME �+ C,4_ a 1�{f t7 �.'fdk EXT' -92-PHONE# `'12-y-3x`81 3q-10 HOME or MAILING ADDRESSFAx# 1311 (a2_) X21 -74'10 CITY STATE / _ ZIP 4. ( 6"7 Q BILLING ACKNOWLEDGEMENT: 1. the undersigned property or business owner, op-erator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONNIFNTAL HrA[.['H DEPARTMLNf hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes,Standards,STAT and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: (T/17 1O 7 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AuTIIORIZED AGENT If APPIJCA NT is not the BILLING PART/',proof of authorization to sign is required 14 Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUN'T'Y ENVIRONMENTAL HLA[..TH DLPARTMEN'C as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: 1A ST PF2.MA-(3G11 CL0<-; E RECEIVED COMMENTS: AUG n 4 2007 SAN JOAG)UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE#: DATE: ASSIGNED TO: r EMPLOYEE#: 4e, DATE: Date Service Completed (if already completed): SERVICE CODE: Z)3 tk P i E:0; ,l Fee Amount: QR , Amount Paid Payment Date Payment Type Invoice# Check# a Lk4� Received By: EHD 48-02-025 �,, SR FORM(Golden REVISED 1111712003 � X2 ;. g(��-•