Laserfiche WebLink
IREECEHL � <br /> SAN JOAQUACOUNTY ENVIRONMENTAL HEALTH DEPARTMENT NOV 2 5 2009 <br /> SERVICE REQUEST t LTH <br /> Type of Business or Property FACILITY ID# SER I ERi.Fsi#RV10E <br /> � <br /> OWNER/OPERATOR <br /> P�.�-• �:c a o- E I ectr;(� CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> ?A +6 s-rocNt'on Serv;c.e c.ente c' ✓ <br /> SITE ADDRESS LIOyO Wes.r (_cine .5fc& -r0,1 I 9--201 <br /> Street Number Direction Street Name I city2i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3yt7I Lfoa.! Cony ort Coq <br /> Street Number Street Name <br /> Ciry p STATE ZIP / SO <br /> San I3 Iia/r-1on Ca. / ISOD <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> R09) 60-2 703 5 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �an �CJ) Eco l..�t1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME IJ PHONE# Ex'' <br /> Gettler- F.'J4n Ac. P46 618 <br /> HOME Or MAILING ADDRESS FAX# <br /> 3 io Gol Carte r. Su' e- / ( 511 ) 63 /3/ 7 <br /> CITY Cr1 o relSTATE ZIP (�s6 7� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENvUtONMENTAL HEALTH DEPARTMENT 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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA EDERAL laws. <br /> E: p <br /> APPLICANT'S SIGNATURC- � io-- DATE: <br /> (SI LOI <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT 10 rvre-e PICrnti2er <br /> ffAPPL/CANT is not the B/LLtyGPAKTY proof of authorization to sign is required rifle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,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 JOAQum COUNTY ENv1RONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ''--rr U / �_ V <br /> COMMENTS: Retf(4Ce yresel d;rec.t bury sp. 11 r-IanF349F-x <br /> ��� 2 5 1009 <br /> ReP�G//cc w.'t��,/ nem✓ oP/.d/.1 // <br /> r ' _e/,_ ICC C I7� 4�6��7� SAENVR NIP T V <br /> ACCEPTED BY 0 EMPLOYEE#: DATE: <br /> ASSIGNEDTO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: 3 y,S� Amount Paid 1 lf/S'I Payment Date �� 'LSJ O <br /> Payment TypeCred;t t"gr(Y Invoice# Check# Received By: \v 0 <br /> con$�rnrt.d,n � A67843 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />