Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTALPw�AL 11-thrA-m "ate " <br /> SERVICE REQUES t <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property //� <br /> OWNER OPERATOR Rw / '`,- ��('�{/�U, c. ^` CHECK ifZBBIILLINGADDRESS <br /> FACILITY NAME cif <br /> SITE ADDRESS5555 1/f G ��'�� �" �� <br /> CI Zip ode <br /> Street Number Direction Street Name '�'� 9q _! <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 3 2`-Y W ec <br /> Street Number Street Name <br /> STATE I <br /> CITY <br /> Exr. APN# LAND USE PLICATION# <br /> PHONE#1 f 7(J <br /> ( ) BOS DISTRICT LOCATION CODE <br /> PHONE#2 <br /> EXT. <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> FAx# CHECK <br /> H <br /> ECK If BILLING <br /> N�G AOD�DR <br /> ESS <br /> EXT. <br /> BUSINESS NAME DES(G,� q-5�0C,17� P #) q , <br /> HOME or,MAILING ADDRESS /FO <br /> L STA ZIP ' <br /> CITY <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 form. <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 laws. <br /> APPLICANT'S SIGNATURE: DATE' ©S 2� <br /> PROPERTY/BUSINESS OWNER❑ OPERA OR/MANAGER ❑ OTBER AUTHORIZED AGENT <br /> iIf APPLICANT is not the BILL/ GPARTY 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 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. <br /> TYPE OF SERVICE REQUESTED: rV t7X�-rf-I ��`--�t^��- SatL [L - STt-'C'7 <br /> lvl�COMMENTS: <br /> h rya� �� RECEIVED r �l�/ <br /> I/[I� MAY 2 2 2007 <br /> 0 SIdENVIRONMENTAL <br /> ACCEPTED BY: �'�_IV 44 EMPLOYEE#: z_/ DATE: 07 <br /> ASSIGNED TO: 410 EMPLOYEE#: 'T-fO S' DATE: (CI <br /> Date Service Completed (if already completed): SERVICE CODE: fi"Z- PIE: <br /> Fee Amount: Amount Paid I{-7 S- r10 Payment Date <br /> Payment Type Invoice# Check# IOyrl VI.S.c17-� Received By: 2�-- <br /> l�S — tf 0-[T-D SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/1712003 <br />