Laserfiche WebLink
SAN JOAQUIN -,`AUNTY ENVIRONMENTAL HEALTH ',PARTMENT <br /> St ;RTy",NCE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C,C`�G ��1.��s s <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> VA L <br /> SITE ADDRESS / _/� Okcok- RWID StDr-/<to;-) g5Z�Z <br /> Zr7 Z,3Street Number Direction Street Name Ci ,Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) /L/rye-I-�„I 9L 'bI71 VE. <br /> KStreet Number Street Name <br /> CITY STATE ZIP <br /> 'S 7?SGIc <br /> -to/L-, S2. <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Z'n ) q S3 701 S 17-8-110 -16 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) Z <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> _1Z'J <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> Z Z Zo*'� 5 tt��-fi (?I, ) <br /> CITY L'dG 2A1±1 L v STATE CA ZIP S p I' <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 form. <br /> I also certify that 1 have prepared this applica 'on and that work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA an ED aws. <br /> APPLICANT'S SIGNATURE: DATE: 8/ZC ZfJO tr <br /> PROPERTY/BUSINESS OWNER❑ ERA R rqA4GER ❑ OTHER AUTHORIZED AGENT O 4 9.j,l(1T-6-- ,T- <br /> If APPLICANT is not the BILLING PA proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFO ATION: 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 enviromnental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. r-60j-') i9LAyJ C f-{et�jf- .— 2 �-( fL--_ <br /> TYPE OF SERVICE REQUESTED: E�-D FAG I L t P-4.-51- 609*-L ADDI-r I NT <br /> COMMENTS: fRECEIVED <br /> AUG 2 1 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> FAUN DEPARTMENT <br /> ACCEPTED BY: L L J� i _D .A EMPLOYEE#: Q ?� Z( DATE: Z� <br /> ASSIGNED TO: aE� ��y4�T EMPLOYEE#: 02-i DATE: o <br /> Date Service Completed (if already completed): SERVICE CODE: .S ZZ P/E: ( �p <br /> EeeAount: v� Amount Paid Payment Date gZk( 0�t Type Invoice# Check# Z2 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />