Laserfiche WebLink
i <br /> i <br /> • i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL, HEALTH DEPARTMENT <br /> SERVICE REQUEST J <br /> Type of Business or Property NONNI FACILITY ID /1 ER610REQUEST 1l <br /> INN IN <br /> CL wa;� /r1l <br /> OWNER / OPERATOR <br /> C <br /> rZo // ;000 h �', © � NECItIfPILLIZiOADDRESSli <br /> I <br /> FACILITY NAME <br /> SITEADDRESS <br /> lywz Gn i'8110afflubei �-/aL straot ama f c b1 C! zip <br /> p opae <br /> HOME or MAILING ADDRESS (If Different from site Address) ,3 e) 00" 4e <br /> stray niberSt t <br /> CITY STaTE /; /' '`j QIP <br /> �--�3L I <br /> PHONE #1 OXTO APN # LAND USE APPLICATION # <br /> PHONE12 y � � Exr• BOS DISTRICT LocAnoN CODE <br /> J <br /> CONTRACTOR / SERVICE REQUESTOR <br /> RI~QuESTOR <br /> CNBeH if gILUNe AoDREs3ff <br /> SUSINE9S NAME- Z..�� t -e? ?i � Y✓' P � ft <br /> HOME or MAILING ADDRESS /'� �1j 7 <br /> CITY �"� G• STATE5 � ZIP 's"�� <br /> BILLINGQ ACKNOWLEDGEMENT: 1, 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 Identifled on this form, j <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, STATE and FEDERAL !mss' <br /> APPLICANT' S SIGNATUREo w.. ' `•��� DATE : <br /> PROPERTY / BUSINESS OWNER ❑ 0139F6 MANAGER © OTHERAUTHomzEo AGENT �{ <br /> IfAPPLICANr /s not theJ6gthug PAR LL proof ofaufhor/zatlon to sign Is required Title <br /> AUTHORIZATION TO RE <br /> LgASE INFORMATION : When applicable, 1, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or envlronmental/site assessment Information <br /> to the SAN JOAQUIN COUNTY EFNVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It is provided to me or <br /> my representative. <br /> TYPE OFSERVICE REQUESTED1 e <br /> COMMENT$: h +�: y O��� I <br /> ✓o ?p19 <br /> C <br /> 67pt (� � �rHd pq tFNTq[N� <br /> ACCEPTED BY: EMPLOYEE #; OL 00 DATE: p � TM�NT <br /> 11 I <br /> ASSIGNED T0: �(/� EMPLOYEE #: DATE: <br /> Date Service Camptated (if alreadycompleted): SERVICECCDE: a P / E: <br /> Fee el Amount; Amount Pal b� Payment Date A2 t 1 <br /> PaymonkType Invoice # Check # 2 .--. Recel ed By; <br /> nV <br /> t <br /> .7._ ': r <br /> END 48.02x025 SR FORM: olden Rod) <br /> 07/17(08 <br /> MAR <br /> � NVIR 11NM ; t r , <br /> FPA <br />