Laserfiche WebLink
' SAN JOAQUINVOUNTY ENVIRONMENTAL HEALTH SARTMENT <br /> SERVICE REQUEST <br /> Type of Business Or Property FACILITY ID# SERVICE REQUEST# <br /> L6� s 5 'Zo c s �13 0 <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> Pacific Gas and Electric <br /> FACILITY,NAME <br /> J toclCt on Service Center <br /> SITE ADDRESS q //'1 <br /> 4040 Street Number tion WeSt lane Street Name tock[ 9541 &de <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number $tre.t Name <br /> CITY STATE ZIP <br /> PHONE#t En. APN# LAND USE APPLICATION# <br /> ( 1 117 — bZ0 --01 <br /> PHONE#P En. BOS DISTRICT LOCATION CODE <br /> ( ) y <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS E] <br /> Michael A . Armour <br /> AmourUSINEce NAMEg EZT. <br /> t <br /> Petroleum Service and Equipment Corporatio PHQN�# 437-6668 <br /> HOME Or MAILING ADDRESS FAX/# <br /> PO Box 507 (707) 437-4357 <br /> 9IKaville STATE CA ZIP9 5 6 9 6-0 5 0 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 ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me Or my business as identified on this fo <br /> I also certify that I have prepared this application and that wo t be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S TE nd F Is . <br /> APPLICANT'S SIGNATURE: DATES: 04-20-09 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT M Contractor <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <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 /> inform nh V �,A Y ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the same time it is <br /> o e o pl'e Iv /J —PAYMENT <br /> AW <br /> n <br /> PE �VIC�FIEDUEBTED:• IVtU <br /> % T lr[ G- A 41 Yrs FiECE <br /> COMMENTS: APR 2 4 2009 APR 2 4 2009 <br /> ;:SIN t AUNTY SAN JOAQUIN COUNTY <br /> AL ENVIRONMENTAL <br /> -AT <br /> AL <br /> AL HEALTH DEPARTMENT <br /> ACCEPTED BY: C>(-L U f=t 1,44 <br /> EMPLOYEE#: p 1 2-I DATE: . r&L-1 <br /> 2� Q <br /> ASSIGNED TO: Z A-C�t EMPLOYEE#: 4&36 DATE. Lf 214 Q Cf <br /> Date Service Completed (If already completed): SERVICE CODE: [q b PIE:' 3 D 6 <br /> Fee Amount: 31 �• Amount Paid -43'S O Payment Date O <br /> Payment Type ✓ Invoice# Check# 2277:7Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />