Laserfiche WebLink
,JANJOAQUIN %-OUNIYL'NVIKUvIVIJSvIAI rrc,t+ In <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ulzl,o 5 4 C-S-/ I 5 g5bq <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> HA-Q5A44 I Nc- <br /> FACILf1YNAME a �t2�O5 <br /> SITE ADDRESS 12'-+ kvC MRQTt '� 9533(0 <br /> Street Number Direction Street Name cil Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#I Exr. APN# LAND USE APPLICATION# <br /> l ) 2ZI — 2-0t7-3-s <br /> PHONE#2 E"r. BOS DISTRICT -� LOCATION CODE e I T�- <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR " `-\9AT CHECK If BILLING ADDRESS <br /> BUSINESS NAME Il, G PHONE# EXT' <br /> (20 65 - 48 la <br /> HOME Or MAILING ADDRESS FAX# <br /> GSA C--r l ) <br /> CITY STAf�o-bt5STO C::Ar ZIP c�53St. <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 or <br /> activity will be billed to me or my business as identified on this forret <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 JOAQUN <br /> COUNTY Ordinance Codes,Standards,STATE <br /> �.and <br /> -�FEDERAL laws. <br /> APPLICANT'S SIGNATUIRE:: C/ DATE: l —2 4—O <br /> PROPERTY/BUSINESS OWNER LTJ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 /> information to the SAN JOAQUN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> `y TYPE OF SERVICE REQUESTED: C O!)S LA-LTJ,' f(O tiJ IF /L <br /> �!\ COMMENTS: pp <br /> Y2� SkL.2 "(a, A2271-H INsPt �TlonJ N a T� = e �0 <br /> �w nide � cE! S r n�S PG y�o J R 3 tip0� <br /> ,P�OPO \1AeNUN�-N <br /> ACCEPTED BY: L�L u, g , EMPLOYEE#: C 3 z / DATE' N1 0? <br /> ASSIGNED TO: ;TL � EMPLOYEE#: 3 7 3 DATE: / 3(i/O7 <br /> Date Service Completed (if already completed): P I E: <br /> Fee Amount: S "3 Amount Paid ? _`� ) Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />