SU0006466 SSCRPT - Laserfiche WebLink

Home Browse Search

JANJ0A(2U11N l:0UN1Y LtNV1KONIVILN1Al "LALtri 11J11,rAKLY11,041 SERVICT REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# FJ Z ),!O A„ 5tZeDW 03 OWNER/ OPERATOR El 3b%Wv // AID21C Sc N14FF LA Y zjot-T.Te e CHECK If BILLING ADDRESS FACILITY NAME SITE ADDRESS `?t c/? 2 _ �_ 4-Le Q`-- IXJ� /� Stre umber Direction i' Street Name cit, i�-_(� ZI Code HOME Or MAILING ADDRESS (If Different from Site Address) ^�p� 5 F2 Street Number - "` Street Name CITY STATE /� /I ZIP Q S' 3 PHONE#1C/J EXT. APN# LAND USE CAP/PLIICATION# (209 ) $39-3N31 205- len- l(o f l7 � PHONE#2 EXT- BOS DISTRICT LOCATIO CODE (201 ) 1103 -0/45 CONTRACTOR/ SERVICE REQUESTOR REQUESTOR / AARON DIOL!ISI CHECK If BILLING ADDRESS Ef BUSINESS NAME L] PHONE# EXT. 111p ✓A«eY ,€A/ 1AJBEPVAl6 Zoq I HOME or MAILING ADDRESS FAX# //l7 Y" ,57/Z&,5'f (Z'D4 ) !Z(.-6803 CITY HO/)1i57o STATE CA ZIP 953 541 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,ST TE and FEDERAL laws. APPLICANT'S SIGNATURE:,� /�) P-- DATE: Z11/2-007 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT If APPLICANT is not the BILLING PARTY proof Of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 environmentallsite 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. TYPE OF SERVICE REQUESTED: 6 COMMENTS: 3 q �L /�^yy�r, Lft -tel E1 V D V0 g T (� ` FEB 1 4 2007 ylh-t-vN SAN JOAQUIN COUNTY EVIRONENTAL HEALTH DE ARTME NT ACCEPTED BY EMPLOYEE#: DATE: 6 ASSIGNED TO: 5 EMPLOYEE#: Q y S DATE: Date Service Completed (if already completed): SERVICE CODE: t— P I E:Z O Fee Amount: ( L} Amount Paid Payment Date Payment Type Invoice# Check# Received By: EHD 48-02-025 ' .SR FORM(Golden Rod) REVISED 11/17/2003