Laserfiche WebLink
SAN JOAQUill COUNTY ENVIRONMENTAL HEALTH MitARTMENT <br />SERVICE REQUEST <br />r717)-ipe of Business or Property FACILITY ID # SERVICE REQUEST # <br />5 oo-71 ce 5) <br />OWNER / OPERATOR i <br />m m retirciellets CHECK if BILLING ADDRESS <br />FACILITY NAME -ye i ic;5\A tea rit).5 .i.ec otyvt 1,_) Cot 1 trY1 el <br />SITE ADDRESS 1270 <br />Street Number <br />5 <br />Direction Cal i toeArlt <br />treet Name City Zip Code <br />HOME or MAILING ADDSSS (If Different from Site Address) <br />LA 0 6 T---i I \oeie--i-- Street Number <br />et:A . ic7 Ce ti <br />Street Name <br />STATE ZI CITY ..5.\,...y.1.3 <br />PHONE #1 315k EXT. <br />(1 Ll (21 140 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />MO e:Ack OA vi XvinS CHECK if BILLING ADDRESS <br />BUSINESS NAMET7.l c 04) 6a e-K-Tui--os -\--e WMAn PS11 Ati, <br />x 1., iciexco <br />HOME or MAILING ADDRESS f•3 1.10 4g • W-Old- ‘2P O rl ( ) <br />FAO <br />CITY CAle,scssi c)XTE ZIP <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 Of <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: <br />PROPERTY! BUSINESS OWNER 0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me Of <br />my representative. <br />TYPE OF SERVICE REQUESTED: --y-t,106_ \I OA t as \ft,c,R2 6-1,,i‘.,,,_ ,--49,yme... <br />-NI COMMENTS: UtiliA Vr/y. Dc\ ov11412)21 rk - A - e - <br />Reck,. <br />SEp <br />1? <br />,I:if!4 <br />sk cial 448 eivvili QuIN co HEAto. 0A1108, Wiry <br />H DePARIVrAL <br />ACCEPTED BY: `1 . AU ‘/VtDa EMPLOYEE #: <br />17447 <br />DATE: <br />ASSIGNED TO: yy) . 1...- , EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 0(p t PIE: k)c <br />Fee Amount:4 ,-- / ,-)1._ s Amount Pa4/502 dO Payment Date <br />Payment Type Invoice # Check # Receiv d By/IX <br />DATE: <br />Title <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)