Laserfiche WebLink
SAN IOAQUIN COUNTERENVIRO <br /> V C NMENTAL REQUEST HEALTH DEPARTMENT <br /> ICE REQUEST# <br /> FACILITY ID# SERV <br /> Type Of Business or Property <br /> Svon ia5952- <br /> CHECK if BILLING❑ <br /> OWNER/OPERATOR <br /> FACILITY NAME / �„(�,�nO 'r" <br /> 7 � Zi Code <br /> ' 1 oVP.+ street <br /> Jer�.se a <br /> SITE ADDRESS +yI U Cj 0 ry I Name <br /> Street NumEer Direction me <br /> street Na <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Street Number STATE Zip <br /> CITY LAND USE APPLICATION# PQ -0800�W— ) <br /> EXT. APN# ` -F V IN G,� <br /> PH0NE#1 0rj t° LOCATION CODE <br /> ( ) Bos DISTRICT R <br /> EXT. <br /> PHONE#2 <br /> c ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> CHECK If BILLIN�O <br /> REQUESTORelf— EXT. <br /> ..-w PHONE# <br /> BUSINESS NAME capk_ <br /> `'� � ' FAX# <br /> NOME Or MAILING ADDRESS p, V <br /> O ,L ` ( ) <br /> l -� STATE ��� ZIP pr S 2- O <br /> CITY - ��, .. 1 <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: 1 0 <br /> PROPERTY/BUSINESS OWNER❑ OPE ATOR/ GER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the B/ NGPA2Tr 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. S u t I_ S LL-t 7—,+-A( L--t S` .3 <br /> TYPE OF SERVICE REQUESTED: GESS �/–G�-�f Tj pr-ICENED <br /> COMMENTS: I I/ C./r/+`I/'a , �J 1 g 2008 <br /> SANIN COUVIV <br /> vIFO NMFWN- <br /> 4ALTH ONAPTMENT <br /> ACCEPTED BY: C) (_L L/IC t ,O n EMPLOYEE#: 6 3 Z DATE: ' 009' <br /> ASSIGNED TO: LCJ r– EMPLOYEE#: �'c� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S y v PIE: L1;,01 <br /> nount: ;I—I O, §-�D Amount Paid -f,.>f L d L i Payment Date C ' 0 <br /> Type Invoice# Check# 8' Received By: <br /> 25 SR FORM(Golden Rod) <br /> 17/2003 <br />