SU0003877 SSCRPT - Laserfiche WebLink

Home Browse Search

Of11N .VU1N 1 Y L'INV IKV1N1V1L'1N 1HL KAr.61.117 1/C.1't11(I IVIY.IN 1 SERVICE RE UEST Type of Business or Property FACILITY ID# SERVICE REQUEST# Fie den/ / --J OWNER/OPERATOR CHECK 1/ C-le-ATH CHTs hc/;�.s ✓ dne Q / /9ro es / / C CHECKii BILLING AOORE55� FAcRm NAME ✓•✓ L. L. SITE ADDRESS Z Z Z OS N, �a hnSOn ��, G�Chv�, 9SZ 27 Street Number Direcuon Street Name Ci ZI Cotle HOME Of MAILING ADDRESS (If Different from Site Address) P0 G street Number Street Name Cm r� Y �Gf7 STATE CI ZIP PHONE#I En. APN# LAND USE PLICATION If 7 PHONE#2 Ei. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REOUESTOR C E5/G r n C t ` _ � CHECK if BILLING AOORFSS BUSINESS NAME PHONE# Err, civ /L� e5-A'--&or, Rafl F3/-137 HOME or MAILING ADDRESS FAX# Zze W. 9j/- Z37 CITY / G STOTE ZIP C1�';2 f`D BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. C� APPLICANT'S SIGNATURE: Q DATE: t .26 — b71 PROPERTY/BUSINESS OWNER OPERATOR/MANAGER If OTHER AUTIIORIZEDAGENT O� If A"PPLJCAAT is not the SttLtNG PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time It is provided to me or my representative. �r TYPE OF SERVICE REQUESTED: �QCII/CuJ SUr` < rw Sd 4C (..D/1 N'llrl G.� 6 COMMENTS: /Vo 4tret'cl4,10/ bL3— 030 — 'Fco J � j.1`� IO j ,u� p YIVE;_: G Z 3 —/ — 3 Z � ,_>,..�,. 2 92003 6 Z 3 — 090 -- 6 if SAN",��O�AEAISN SO,VICE ION APPROVED BY: � -�o EMPLOYEE f� C1 C FNVIR SpA ASSIGNED TO: S �t�z r��+ r EMPLOYEE#: / DATE: Date Service Completed (if already completed): SERVICE CODE: PI E �j 3 Fee Amount: ( 7 Amount Paid Payment Date y L Payment Type Invoice# Check# Received By: -