Laserfiche WebLink
SAN JOAQUV' `AUNTY ENVIRONMENTAL HEALTH r-mARTMENT <br /> SERVICE REQUEST <br /> Type of quslness or Property FACILITY ID N SERVICE REQUEST 0 <br /> o c 41.t 510q s 2 1?S,I� <br /> OWNER I OPERATOR <br /> crracrc If MIIuAtQ,B1iogLt <br /> !mi AOD!!p� �„�� � ��C l �'i.,� � 4`� �j C C l�`j�/�: ,f s',,,Q r•. 'i <br /> Holds or MAIUNo ADDRESS (if Different from Site Addreea) <br /> — --... a..«._.,.,..._ Mn•t lANln er aer••�N1fA��. <br /> CITY w 8TAY2 9 zip i <br /> PRONE#1 a>f APN* LAND USE APPLICATION 11 <br /> PHONE#2 Ems• y / - E105 DISTRICT LOCATION CODS <br /> CONTRACTOR OR SERVICE REQUEbTOR __------- ___- <br /> FZECdUEE$TOR ._.��.,__...._�._... <br /> y� j GMECriitIJILWIU <br /> BUSINESS NAME - M T <br /> HOMItorM LIN ADDRE nAl 44 1 f s-) 9&'? _ SS <br /> CITY v (� tor J%V STATE AT)Q( ZIP <br /> BILLING AC KNOWLEDGEMENT: L the undersigned proper-h- I�r husineNll owner, operator or authorized agent of.same, <br /> i 11'knowlodge that Lill site and/Ill'I11'I1,jeet Npeeitic FNN1RI�NhWNTAI.HFtA1.TFf T PTARTNWNT hourly charges associated wish this project <br /> or activity Neill he billed hr me or my husiness as identified on this form. <br /> I also certify that I have prepared this application and that the work to he performcd will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,S7andants,STATE and FEDERAL IaW.S. / <br /> APPLICANT'S SIGN ATI JRI,: DAT11: <br /> I'NOPVRT1'/(itllgNINN t.WNXKQ 01RN:1TOR/NiANAURN Q 0 <br /> 1/'.4PPhlt'4xT iv no/sire B/L,l.x(;I'.4rrTr,prrx f r►J'andtorkatt(rrr it)slApt Is required Tufa <br /> 61,I[TjQ$IZATIOIN TO RE����jNFORMMATION: When applicable,I, Ow owner Llr operator ul'thu property lucntud ut lho <br /> ahuv v Wit- addruhg. hurab� authorize (he r4leow of ata and till rusulim. pw+lvolWcal data trod/or aNNussmunt <br /> inlia'111116 11 to 1119 SAN J0AV19N COLINTY EN\`INI)NKIVNTAI.HEAL.III I)I+I,:>.I(ThINNT N moon e1N it is available and Li( (119 Nilint: (iniv II iN <br /> III(I\0CLI III lne or my repreNtlntati\'e. '( <br /> TYPE OF SERVICE REQUE'JTItIli <br /> COMMENTC: <br /> MAR 3 Tv <br /> 1N GOUN <br /> N�OPOV MENjPL <br /> SP EN\jIRONPPRTMEN� <br /> N pE <br /> ACCEPTED BY: 14EMPLOYKR#: 6 9 <br /> DATI: 0313 r bs <br /> ASSIGNED TO: EMPLOYEE#: �{ 2 ��10 DATI: 023' Qr <br /> Date Bervies Complied (it already completed): 11111!AME CODE! 19e I p/E:a 3 of <br /> Fee Amount: �t,4f Ofl ^, Amount PaidPayment Date — <br /> Payment Type ✓ Invoice# Check# Recelved By: <br /> EMD 48.02.025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />