REMOVAL 2015 - Laserfiche WebLink

Home Browse Search

' SAN JOAQ,..A COUNTY ENVIRONMENTAL HEALThmOEPARTMENT SERVICE REQUEST Type of Business or Property _ FACILITY ID# SERVICE REQUEST# t-,A- 0 0 v 3 OWNER/OPERATOR / v. /Lk r u ) CHECK I( ILLIN A R FACILITY NAME fVC. �L/'/?Svllll�� } ��C�-N 5' v j t'S�fia� 5'Tc� �caJ >« y Street Number I DIte'ti'mStraet Name city Zipode m Site Address) HOME or MAILING ADDRESS (If Different from , Street Number Street Name CITY STATE ZIP PHONE#1 Ezr. APN# LAND USE APPLICATION# (a0 -),clK- 3i93 \ (0 l 0 (--> PHONE#2 E[i. BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR /?j/� �y7l2/�� CHECK If BILLING ADDRE35O BUSINESS NAME V PHONE# En. ZZ, T/��/Z/�c C�/l /�C 1.%) 3i S HOME or MAILING ADDRESS /�� C)/ OX 3 ( I 3 Ax# CITY z./)/ STATE C',; ZIP CL 7/ BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/Or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Or activity will be billed to me or my business as identified on this form. 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, STATE and FEDER S.. APPLICANT'S SIGNATURE: r n �� DATE: —A� PROPERTY/BUSINESS OWNERpQ� OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ /./-6424/rC-/Z If APPLICANT is not the BILLING PARTY Proof Of authorization to sign/5 required Tide 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is pvided to me or my representative. Fura�/ TYPE OF SERVICE REQUESTED: rGG� � fIECEIVED COMMENTS: G' AR 16 2015 SAN JOAQUIN ENV'OMENTAL HEALTH DEPARTMENT ACCEPTED BY: - EMPLOYEE#: DATE: ASSIGNED TO: f EMPLOYEE#: DATE: Date Service Completed (If airea ycompleted): SERVICE CODE: �' /k PIE Z� Fee Amount: '> Amount Pai 39d,D?j Payment Date 3114e /S Payment Type Invoice# Check# 3X9'7 Received By: EHD 48-02-025 SR FORM(Golden Rod) 07/17/08