Laserfiche WebLink
I also certify that I have prepared this applic <br />COUNTY Ordinance Codes, Standards, ST <br />ion and that t e work to be performed will be done in accordance with all SAN JOAQUIN <br />and FEDE laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNEREP OPERATOR / MANAGER Er <br />DATE: <br />OTHER AUTHORIZED AGENT 0 <br />SAN JOAQU -70UNTY ENVIRONMENTAL HEALTL _PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />4 JOC I <br />FACIITYID# ,, /1 BBRACEREQU74 <br />i <br />OWNER! OPERATOR r <br />1 ,0 YaM .1) \co ‘(_k_o Co ‘HC-2- CHECK if BILLING ADDRESS <br />FACILITY NAME t....k.)\ p / /DI y i ock L) <br />SITE ADDRESS ) 1 .01F <br />tre Number Direction <br />ii i „" a .cv )v '' -) • ,_ ite,, ii. J 3\ipc _i/v -\ <br />city <br />q52bt <br />Zip Code <br />HOME or MAILING ADDRESS 1.1..f_Meilttom Sitetncy cX i <br />1 t Street Number Street Name <br />CITY ...) \.A.,,)(...„,k6 V\ STAT,E c yj s---20 b <br /> <br />t-1,1 <br />Z <br />PHONE1 EXT. <br />( 2D ?).9S/35-).-Q- <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME 05 1.... Qm\(opad ' Pli5mE# Ex r. <br />?M33- ZC <br />HOME or MAILING AD,DREBS A 1 ka 1 Y . FAX # <br />Cry S 1 /46 4 A-c1 STATE c.--- ,,i ZIP '5 ?(::_) c. <br />BILLINGACKNOWLEDGEMENT: 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 <br />or activity will be billed to me or my business as identified on this form. <br />If APPLICANT is not the BILLING PARTY, 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 tametime it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: M 019111 roc/ coils 14 11114i dil 'N'Cirl") Ile pi <br />COMMENTS: <br />Clian9t <br />Of OtAi <br />Dee 4.0 1 <br />I <br />& -0,1n iv: 2a1.9 I ( (C—Cr II <br />, <br />V <br />lief 41LIP w °I Crii ON* 04,, 04,1„21/7-41. fr <br />1174fEivr <br />ACCEPTED BY: LO r---r/ . a c_ , EMPLOYEE #: q 27 0 DATE: 1,2_,1 IG:211q <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: <br />C Li/ <br />PIE: / (00:3 <br />Fee Amount_ ( e 7, ._, rd Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003