Laserfiche WebLink
SAN JOAQUIN UNTX 3ENVA0NMENTAL HEALTx DEI MAIA <br /> SERVICE REQUEST <br /> Type of Business or property FACILITY ID# SERVICE REQUEST; <br /> Ca AS GTA-TlOtq PACO/2 532 520044309 <br /> OWNER I OPERATOR 6HOK if BiLuwa ADDRESS 1 3 <br /> Clieu P,Orj <br /> FACILITY NAME A <br /> SITEADDRESS � ��' �LI�e '�IG�VLl(JV <br /> street umbar trcetlan Sire c C 2i Catl <br /> Hom;or MAILING ADDRESS of Different from site Address) <br /> street Number street Na a <br /> Cay STATE ZIP <br /> PHONE#1 E%Y, qpN# LAND USE APPLICATION# <br /> } <br /> PHONE02 80SDISTRICT LoCAnoNCODE <br /> } <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR ` p B i ' CNECKIf BILLING ADDRESS® <br /> 8usttaess NAME <br /> IP (�3 9 <br /> Ho oLMAILIN ADDRESS PAx# <br /> X40+ ,, S st Cdr a � 0 <br /> GIT' S'OAA- 'k'f STATE 64_ ZIP <br /> BII.LINQ ACKNOWLEDGEMENT; I,the undersigned property or business owner,operator Or autharized agent of same, <br /> acknowledge that all site and/or project specific ENviRONtv.N1',Ab HEALTH DEPARTMENT hourly charges associated with this project ` <br /> or activity will be billed to me or my business as identified oz1 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 FrDERAL laws. p ' <br /> APPLICANT'S SIGNATURE: _ Cr e L i �1- E Z L'L LL DATE: <br /> P>zar€tsTYJ Basrrrnss Owr 130 rOR1 MANAZMt +pT,mAuTjwRrt.>�Ac-qT M &XALt�i u_CQ <br /> X,f APPLICAM is not fhe BILLING PART y proof of authorisation to sign is required Title <br /> owner or opera <br /> of the ro erty located at the " ' <br /> le I the;ow <br /> 'ca P <br /> QN: When app 1t b P <br /> A TI'DO'ItI�TIdN TO RFtii.E.hSE INFORI�Tj,�TI , <br /> above site address,hereby authorize the release of any and an results, geotechnical data and/or c nviront><Zental/sitc assessment ' <br /> information to the SAN JoAQuIN Cowff ENVIItONivIEWAL HJ ALTH 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_ LIST �/T <br /> COMMENTS:a I VL5 f(-U I V lbeLe 0A hoctsck t� <br /> Yz, <br /> ACCEPTED BY: EMPLOYEE#: 03 2. 1 DATE: (O !2 O$ <br /> AMONEO TO' EMPLOYEE#: 3 DATE: (C)112-105 <br /> Date Service Completed"(It already completed): St MCC CODE r c}� a�e: Z 3 oQ <br /> Fee Amount: .279,00 AmountPatd ci< 80 Payment Date <br /> Payment Type i/ Invoice# Ch®ck# r 78 Received By: L—G- <br /> EMD48-02.025 . PAYMEWORM(Golden R <br /> REVISED 1111712003 RECEIVED <br /> OCT 12 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />