Laserfiche WebLink
03/1112016 18: 58 9163712540 B7 1VIAINT PAGE 03103 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT APR 0 6 2016 <br /> SERVICE REQUEST _ <br /> Type of Business or Property. FACILITY 10 SERVICE REQUEST# <br /> L l ex- <br /> OWNER 10 PERA70R <br /> CHELx If BILLING ADDREssPJ <br /> FACILITY NAME 1y��-t����� �� )� / ,, <br /> SITE AbpRE56 i !J vv IY 'S 7� <br /> 51reet Number Ir fittest N i LI e <br /> HOME Or MAILINGAIX)RESS (If Different from 81te Address) <br /> 5lreat Num6gr 1 N6- <br /> -CITY STATE ZIP <br /> NOW#1 EXT. APN# LAND U&r APPLICATION 4 <br /> S 1 <br /> PHONE#2 EMT. VOS DISTRICT LOCATION CDDE <br /> ( r <br /> CONTRACTOR / SERVICE R-EQUESTOR <br /> RE41UESTOR <br /> CHECK If BauN!�AUURE,9313 <br /> SusiNrEss NAME PHQNE# <br /> HOME or MA:LINc ADDRESS FAx# <br /> CITY STATE zip <br /> BILLING ACKNQWLEDGFMENT; I, tho undersignegl property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/or project SPVGifia ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated mth this project or <br /> activity wlll be billed to me OF my business as identified on this form, <br /> I also certify that I have prepared this application and than the work to be parformed will he done in accordance with all SAN JoAauIN <br /> COUNTY Ordinance Codes, StandardsEPERATORIMANAr.ER <br /> FnDE L!taws. `` <br /> APPLICANT'S SIGNATURE: f DATE: <br /> PROPERTYI Buss JEs,30wNr-R❑ ❑ OTHER AUTHORIZEp AGENT 0 <br /> If APPOCANT is not thO BILLING PART r proof of authorization to 519n is required Tithr <br /> AUT1410fUZATION TO RELLA 1� INFORMAT N: Whon.appgr-able, I, the owner or operator of the property located at the above <br /> 61te address, hereby authorize the release of any and all iresults, geotechnical data and/or environmental/ski assessment Information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAW-HENT 816 soon as it is available and at the same time it is provided to me or <br /> my reprosentative. <br /> TYPE OF SERVICE RFOUESTEU: <br /> C06SMENTB: <br /> ACGEPTED By: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE 9: DATE: <br /> Date ServlGe Comploted (if already avmpletod); SERvicE Coor! <br /> Fee Amount: Attlourrt POW Payment Date <br /> Payment Typa Invoice A Check# µ Received 13y; <br /> FHD 4V-02-025 5R FORM(Golden Rod) <br /> 07117108 <br />