Laserfiche WebLink
04-22-04 12:37pm From-TAIT ENVI `ITAL 714-560-8237 T-095 P.01/01 F-025 <br />04/22/2004 12:22 4640138 ENVIRQNMENTAL HED. i PAGE 01 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type or eushns or Property <br />FACILITY ID # <br />BUSINESS Nang <br />fj d/4W,*7,Qur�eC. i <br />SERVICE REQUEST >I <br />0WNER I OPERATOR13 <br />4U �� CIO a,- ro u c L C <br />CHECK If $ILGNt9 �poReSS <br />PACIUIT NAME An L,/) <br />SITEADRRi:55 <br />u- <br />LL: <br />Stye <br />HOME or MNG MDR= (h Different from Site Address) <br />Crr►' <br />STATE ZIP <br />Plsone #1 �' <br />TWN 0 <br />.LAND Use APPucATIoN II <br />PHONEi1x ►• <br />SOS Dk$TkleT <br />LocAT1oH COpC <br />rnNT YI A [ TnR / SRRVIX711Z REOTMSTOR <br />REQUESTOR cHecKif.B iNr_Ann 0 <br />G <br />BUSINESS Nang <br />fj d/4W,*7,Qur�eC. i <br />PHONEdi mss• <br />HOMH or MAILING ADDRESS <br />e�S <br />FAX S <br />7ie1 ��5� OD/�O <br />CITY STA'm <br />13JLLW0 ACTOOWLEDGEMENT: 1, the undersigned property or business owner, operator or autnolrtzea agent or sama <br />j%CJmowlcdgc tbat all •site and/or project specif i; E1 rvIRONMLKTAt- Hr-ALTK D5PARTMhNT hotirly charges associated with this project of <br />activity will be Wed to the or My business as Idenrified on this form. <br />T also ccrtify that I have pT"md this application and that the work to be performed will be done in accordance with all SAN ]OAQUP, <br />COW,NTY O►dina►rca Codas, Srandar4y, STAT!; and FEVEkAL laws- <br />APPLICANTIS SIGNATUM.- 1. DATE:: <br />P, orl:RTY/SUSIMSOWN6R❑ OPERATOR/MANAGER Q 011frRRAvmoRIZEAAGENT WI Co�IQli�z.y�e /+.va.� <br />I•fAPPLICANT is not the ftxLy L&a tv sign u "mired T.rle <br />,1)TKd317AT1ON :12 R -RAgr =QRMAT1Q3K Wk= applicable, 1, the owner or operator of the property located at the <br />above site adaess, hereby authodze the release of wW =4 alY results, geoWebm ical d= 31Wor enviroameatnUaite assesxmen <br />information to the SAN JOAQUIN COLI iM ENVmONMgNTAL HEAI.TM DEpA8.TMENT as soon as it is availab)C and at the same cisme it i.- <br />provided <br />sprovided to Tnc or my represenwive. <br />-771 <br />TYPE OF 5ERMCE REQUEMD: r /�( J`GG • `� <br />A�„ 2 %zoo, <br />ACCEPTED BY.--- rEM> LIOnrl Of �'' CLl C <br />d TO' BMDLOY� ft- <br />ZZICNeL Ll <br />Date Service Completed (if already completed): R WE CODE <br />Fee Amoynt: Amount Paid � • Com. Payment Data <br />T a, <br />P�ayrncnt Type Invoice Choak <br />EHD 49-02025 <br />REVISED 11/17/2003 <br />QUIN coulvr�� <br />SAN JO ON ENTAL <br />RATE" - <br />DATE: <br />PI_ E�v� 3�J <br />Recc:ved Bar. <br />SR FORM (GOdOn Fioa <br />r <br />e, <br />