Laserfiche WebLink
SANJOA V COUNTY ENVIRONMENTAL REAL-EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property II FACILITY ID# SERVICE REQUEST/# <br /> C i t e c - cl tdLV Ao V ACX S96a <br /> OWNE /OPERATORL/I 64n <br /> } t O_\ ECK if BILLING ADDRESS <br /> IFACILITYNAM <br /> SITE ADDRESS b ' , , q �I,—Z <br /> Street NumberDirectlon SimiN. e C`-1 Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) iI -LS0 ' ` L ,�U <' Y (I li O <br /> `T (V` `i S' �U i. moi+ s O <br /> Street Number 1 jN <br /> CITYT 1 STATE <br /> 6 C-L <br /> �Ll <br /> PH0NE#1 EXT. APN# LAND USE APPLICATION <br /> (Zd ) %3l - 541 ! tfS- a7o_pq <br /> PHONE#2 EXT, BOS DISTRICT =ODE <br /> I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR nTUbi I ' CHECK If BILLING ADDRESS <br /> I O �t'�Vt T �n� tL L`V\tn <br /> BUSINESS NAM Fre PHONE# EXT. <br /> Cilr m - i dG� to u 11 war-- 7- 013-7 <br /> HOME or MAILING ADDR S FAXA' <br /> ' ( I <br /> CITY S,Cv�4� � STATE ! .n ZIP <br /> ' BILLING ACKNOWLEDGEMENT: I, the undersigned property m 6osiness owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HFi,ITRISEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identifiedon this <br /> ' I also certify that I have prepared this application and that the work to 6e will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar and ERAL laws. g' <br /> APPLICANT'S SIGNATURE: _,. DATE: 6 <br /> PROPERTY/BUSINESS OWNER RA OR A AGER wa AGMT❑ <br /> If APPLICANT is not the xrr Proajoj Y ,dq'd 'a Titre <br /> AUTHORIZATION TO RELEASE INFORMATION: When apDhcable; s e o Lr or operator of the property located at the <br /> I 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 HEALTH.DEPARTMENT a5 SOOn as it is available and At the same time it is <br /> provided to me or my representative. <br /> ' TYPE OF SERVICE REQUESTED: (�S j Z,LZ(n.v . �(,Dr ,L�n L Z{ N'y- <br /> COMMENTS: REC ?Z-.&V I F— <br /> R <br /> RUSH J U <br /> 19 2008 <br /> SP ENU1Ei0NMEN'TPL �/ <br /> I DEPARTMEt'� <br /> ACCEPTED BY: (J LL V F t EMPLOYEE*#: 3.Z/ DATE: 11 /(,flog <br /> ASSIGNED TO: vO F—L—L c r-- I EMPLOYEE#: 0'-31 -7 DATE: it (,7/0.0 <br /> Date Service Completed (if already co td)' SERYICECODE: Q3 PIE:,2,,3o <br /> Fee Amount. 3/5 vO I.se- ountPa(d L{ �2, S Payment bate ` ct p%R <br /> ' Payment Type Invoice# Check# $ \3 � Received By: <br /> EHD 48-02-025 <br /> SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />