Laserfiche WebLink
SAN JOAQUIN COUN"I'Y ENVIRONMEN•I'AL HEAL'1'H DEPAR'I'MEN'1' <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> E i, 1n G I U 00 44 <br /> OWNER I OPERATOR, <br /> CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME �1'� ��`l�c — 1c�(�,�� �J 1� �t'1�t"•t <br /> SITE ADDRE�f55FX, t rl <br /> / J str..c.. Dvr.cm✓n <br /> HOME or MouupG ADDRESS (If Different from Site Address) 1 <br /> `1 <br /> CITY <br /> J.� Strwt Numtr.r Str..t w'w. <br /> / _� ` . �L�L� ► \ NATE <br /> 3 <br /> PHONE#t Ext APN# U►MO USE APPLICArON# <br /> (5 lyre1 <br /> PHONE#2 Ext BOS DISTRICT LOCAmm Com <br /> ( ) <br /> CONTRACTOR / SERVICE: REQUESTOR <br /> REoueSTOR <br /> L L 4 C.HECRrf BLUING AooREaa❑ <br /> \ p ExT <br /> !Mr—g4rurn Iv)� 7-61 '�X's- 315� <br /> Howirwr ADDREtSS Fmi# <br /> CITY \ xr+ STATE -, j, Zip ".N,° <br /> t <br /> BILLLNG ACKNOWLEDGEMENT- 1, the undersigned property or business owner, operator or authorized agent of same, <br /> ackrxtwiedgc that aii site andior project specific I;.NVIRoNMF\T�I HI Al FII DI`I'ARTMFNT hourly charges associated with this prnjecl <br /> or activity will he billed to me or my business as Identified on thl. Limo <br /> 1 also certify that I have prepared this application and that the work to be perlo nted will be done In accordance with all SAN JOAQUI\ <br /> O NTY Ordinuntr Codev,Standard%, '0 ATF and FFDF.RAI.laws. <br /> �\1 <br /> APPLICANT'S SIGNATURE:� 1�C 11A -' DATE: Co, — (c, <br /> VROPFRTY /BLI,ytNE&SOWNFRW, 0PEItATO1L MAIIA(:ER ❑ OTHER A THlMt12XUAGENT❑ -- -- <br /> 11 APP/_/('ANT is nut the HIL JAG/'ART}',Proof of au/hori,-ation to.sign is rgNired Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br /> alcove site address, hereby authonze the release of any and ;III results, geotechnical data and/or environmental/site ass:ssmenl <br /> mlormation to the SANt JO AO[:]N COUNTY GNVIRONMFNTAL Hi �I III DFI'ARTMFNT as soon as it is available and at the same time It is <br /> provided to me or my representative. p(y <br /> TYPE OF SEttME REQUESTED:IVF <br /> -Q.Sj2 f-64 L 40 --QLk L 12 C <br /> juL 10 2oa6 <br /> "-� —PdVIP,GN�JiENI NES TH <br /> ACCEPTEn BY: / _ EMPLOYEE#. - DATE: . <br /> ASSIGN®TO: EMPLOYEE#: DATE: <br /> Date Service Con4"ted (if already carrmplard): SERVICE CODE: ` P I E: 2 0 <br /> Fee Amount: ` C Amount Paid q rte?, Payment Da be !1 <br /> Payment Type Imroice# Check#1 V U� RSI <br /> EHD 48-02-025 <br /> REVISED 11117/2003 SR FORM(Golden Rod) <br />