Laserfiche WebLink
-�,,UD <br /> rL <br /> SAN JOAQUIPCOUNTY ENV1R43NMENTAL HEALTHMEPARTMENT ?1109 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S Ewp <br /> �A-5 --5�tTLO t-A 6r, 1 <br /> OWNER/OPERATOR <br /> I e:StY10 CHECK if BILLING ADDRESSO <br /> l <br /> FACILITY NAME Is A I <br /> SITE ADDRESS q0tWk�eqkOka il;4 LmL <br /> Street Number I Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> 3ICI-0 V -3 " <br /> 44 *Ck- <br /> Street Number Street Name <br /> CITY A-ubQv'ix STATE VJA zip Cl ttl 01 <br /> PHONE#1 EXT. <br /> N# LAND USE APPLICATION# <br /> 0 6 —7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR WCL-k�k CHECK if BILLING ADDRESSIR <br /> BUSINESS NAME PHONE# EXT. <br /> scv^Q�� S+d.�'-Cto &4SA--e-W-5i ML2 (-/&) W'3 <br /> HOME or MAILING ADDRESSA, C FAx# <br /> 6 8b (ZW) a-c's o <br /> CITY 'S&y' STATE C zip qM <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 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 /> A` e16 <br /> APPLICANT'S SIGNATURE: N-W�-UAJI'V- -1' DATE: S/241 Q400 -7 <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Cc vu 0--a—C <br /> 9 --e 6*tw <br /> IfAPPLICANT is not the BiLLiAG PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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. <br /> TYPE OF SERVICE REQUESTED: iV'VbRr-+Lt;-1 <br /> COMMENTS: -4Z. Jp o-Le-L,4c>( V-'CT 6-c-e(u4 <br /> ckt Lot- vos <br /> P`�o�oNM����N <br /> H <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE- <br /> 1 Z2� 9�2 <br /> Fee Amount: Amount Paid 5 Payment Date 3 L-k 16 1 <br /> Payment Type ✓ Invoice# Check# Gi Received--- eceived By: <br /> EHD 48-02-025 SIR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />