Laserfiche WebLink
2004 16:30 2094""t"""33 FIFTH FLOOR <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH )EPARTMENT <br />SERVICE REQUEST <br />PAGE ©4 <br />Type of Business or Prop <br />R sv aE0U <br />FACILITY ID # <br />SERVICE REQUEST # <br />`{ y <br />t�y <br />OWNS OPERATCHECKtIFACILITY <br />EMPLOYEE N: 3 <br />CHECK It BILLING ADDRESS <br />NAMFT�,�L <br />_ <br />SITE ADDRESS �qy� b <br />VStreet Numbcr <br />Direelloo <br />^ .t�Q 00<(�.� <br />N SVr. et Nam. <br />SERVICE CODE: ' jr. <br />��. / _ <br />`-\1` <br />cifx <br />(� <br />fZI Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Payment Date) aL iv l{ <br />i <br />Street Name <br />CITY <br />I <br />STATfrJL/ 'F <br />STATE ZIP <br />PHONE 91 Exr• <br />APN.ri <br />LAND USE APPLICATION B <br />PHONE Ai Ext• <br />c ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SE RVICE RE O <br />REQUESTOR <br />COMMENTS: <br />RV <br />DEC — 7 2004 <br />SAN JOAOUIN COUNTY <br />ENVIRONMENTAL { <br />HEALTH DEPARTMENT <br />� <br />i <br />EMPLOYEE N: 3 <br />CHECK It BILLING ADDRESS <br />BUSINESS NAMEI <br />55T 7-tT7 a � &a t <br />_ <br />PHONE 0 <br />q <br />E'r <br />HOWE or MAILING ADDRESS <br />SERVICE CODE: ' jr. <br />FAx <br />Fee Amount: n/ O <br />Q I <br />,:.- <br />Payment Date) aL iv l{ <br />CITY <br />STATfrJL/ 'F <br />ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property. or business owner, operator or. authorized agent of snnu, <br />acknowledge Ilial all site and/or project speeif►e EWIRONMEN'rAL l•IGALTt't DCPARTMGNT hourly charges associated with this project or <br />activity will be billed to nie or illy 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 />OUN'1'Y Ordinance Cudrs, SranrltrrdY TA'rE and FCDCRA <br />Li CANT'S SIGNATURE: DAI''E: 19 J _ <br />PROPERTY/ BUSINESS OWNER❑ OPERATOIt/ MANACeti OTHEIt AUTIIORIZCD Acr•,IVT <br />/fAPl'I,ICANT iS /lot the rBl1JdNG PARTY, proof of atirhorftalion to sign is rer/uired Tirle <br />AUTHORIZA'rION TO JRi;I.EASF. 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 />uTfOr=TiOtl 10 the SAN 1OAQUIN COUNTY E-NVIRONMENTAL HLAL't't•I DEPARTMIENT as SOOD as it is available and at the sanic time it is <br />provided to me or my representative. i <br />TYPE OF SERVICE REQUESTED: L,( -,S' T- �l — �% 1 r� PAYMEN-T <br />COMMENTS: <br />RV <br />DEC — 7 2004 <br />SAN JOAOUIN COUNTY <br />ENVIRONMENTAL { <br />HEALTH DEPARTMENT <br />APPROVE® BY: D(,I Jap A <br />EMPLOYEE N: 3 <br />DATE: J 2 Z Q <br />ASSIGNED TO: �� � <br />EMPLOYEE N: r& -7 <br />DATE: f -7 (% <br />Date Service Completed (it already completed): <br />SERVICE CODE: ' jr. <br />P i E:.,7,3. <br />Fee Amount: n/ O <br />Amount Paid <br />,:.- <br />Payment Date) aL iv l{ <br />Payment Type <br />invoice 0 <br />Check It ® <br />Received By <br />EHO 40-01.025 <br />REVISED.6.5=02 <br />SERVICE REQUESr FoRrvl <br />