Laserfiche WebLink
0 <br /> SAN JOAQUIN COUNTY ENVIRONMEN'T'AL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> rztj1 NQ JIS PY1SIh �A oOo38/S 51200�1�34 <br /> OWNER V/1OP TOR <br /> CJY7 czNY ill"""1 I ov-I CHECK It BILLING ADDRESS❑ <br /> FADIUTYH MEn OOa,, �� . r <br /> SITEADDRESS �) 1 <br /> �U Street Number Diracbon I Lod; 5jyo <br /> Street Name �" (� C ZIP Caaa <br /> HOME Of IMAcIUNG ADDRESS (N DiffereMfmm Site Address) 1�QnCht7 �i1eSU �/� . <br /> 0 J Street Number abeet Nemo <br /> CISTATE ZIP <br /> 2lv�r �Qr�( (-.L* Cll3d-J <br /> PHONE 91 Ear APN# LAND USE APPLICATION# <br /> 180,51 alp-qac, 15a <br /> PHONE#2 <br /> 1 Exr. <br /> BOS DISTRICT LOCATION CODE <br /> f <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REUUEST-1O1R '�r}—'�,I1I"� ✓�rLL �I <br /> �`1 r`S CHECK If BILLING ADDRESS <br /> BUSINESSA��In�r-.•E,, <br /> USW <X3J�/A14 f1Oki PtSc� J rJ. � 'cJfa E.. <br /> E rMOUNGADo I�s S FAX* <br /> cam, i�.4tJ �sne'� �I gid. <br /> CITY NO',)bur STATE LP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or pro Let specific ENVIRONNfENTAI. HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will he hilted to me or my business as identified on this fonU. <br /> 1 also Certily 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 Codec,Srandardc,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ,1�C7T 4 E IJ t /-)0j—i s <br /> ..rr/T//rr DATE: <br /> PROPERTY/BUSINESS OWNEROl.1 OPERA /MANAGER [3 OTHER ALITHORIZED AGENT 13- <br /> //APRL/CANT��,��,i\is nur the B2L/NG PART) proofojatthorizarion resign is required Tir/e <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1, 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 HEALTII DEPARTMENT as sem as it is available and at the same time it is <br /> provided to me or my representative. <br /> r <br /> VICE REQUESTED: 0.� -� F U R (l _ t y_ C.( S I�Ve 5�,,0� �m -}U S J �u���i Q 1� RECEIVED <br /> e to S etiu L �e l�z MAF 2 2 200 <br /> SAN JOAQUIN COUN <br /> ACCEPTED BY: C/r� ONMENTAL <br /> DATEL It,� ) 1 EMPLOYEE#: �" 2 i : Ps <br /> . T <br /> ���� <br /> ASSIGNED TO: 0 � ..,��(� EMPLOYEEM <br /> �'j P� DATE: <br /> Date Service Completed in already completed): <br /> sElmcE CODE: 't 9 Er PIE: �3 o k <br /> Fee Amount: �-7c/ CJ Amount Paid q <br /> Payment r Z) o Payment Date 3? 2.Z <br /> Type Invoice# Check# 3 Ile Received By: <br /> EHD 48-02-025 REVISED 11/17/2003 IE Ev*O olden Rod)J%\ <br /> ' <br /> MAR 2 2 2005 <br /> CNVIPQ)J C-NTHFAITH <br />