Laserfiche WebLink
vn(� dVAVUnN %-VUIYI IT nNy I IfUNMLN'1'AL.IME ALT DEPAIITMENT <br /> SERVICE REQUEST <br /> [FAciLiTy <br /> pe of Business or PPrroop^ertty FACILITY ID# SERVICE REQUEST# <br /> a f� V`oil <br /> WNER/OPERA/TOR (''� <br /> CHECK if BILLING ADDRESS <br /> NAME <br /> READORESS Z5D0 w LOGr+, TVe- a a� <br /> Street Number Dlreetlon �"�' <br /> Street <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Name cft Zip Cod. <br /> Straot Number Simet Namo <br /> CITY STATE Zip <br /> PHONE#1 Ezr. APN# LAND USE APPLICATION# <br /> I,oR) 333 3 <br /> PHONE#2 EXr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS E] <br /> BUSINESS NAME <br /> PHONE# Ezr. <br /> HOME Or MAILING ADDRESS 20 Z <br /> FAX# <br /> (1v?) 3&S ISY,3 <br /> CIN 1•••/ O-` STATE ZIP <br /> S 2,40 <br /> BILLING ACKNOWLEDGEMENT: 1, the Undersigned property Or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/Or project specific ENVIRONMENTAL HEALTH DEPARIMrNT 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 perlormed will be dune in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codas,Slanc&o•cLY,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE:_ /yy1d <br /> PRpPERrY18USINESSOVVNER0 OPERATOR/MANAGER ❑ OTHLR AUTuOluml)AGENT <br /> 1/-APPL1CIN7'i.Y 170111le BILLINGPdlt7Y 171*00fOf(111111orilalion 10 Sign is required rille <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/silt assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL'1'11 DEPARTMENT as soon as it is available and at the some time it is <br /> provided to me Or my representative. <br /> TYPE OF SERVICE REQUESTED: US^"- > -4EI C�F (—F `vED <br /> COMMENTS: <br /> OCT 5 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: 0L[ (/.E(" EMPLOYEE#: 032-fDATE: 10 S O <br /> ASSIGNEDTO: CA,-f-4/1 1a C EMPLOYEE#: 603&. DATE: IC S O <br /> Date Service Completed (if already completed): SERVICE CODE: (� P I E: 2 3 <br /> Fee Amount4l.2Z e) J Amount Paid .22 g' Payment Date to 6' 0 <br /> Payment Type Invoice# Check#a / Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />