|
r
<br /> r
<br /> 3
<br /> $ N 10AQ1lIN C®Uf�TY�IiiIRONIVV�ENTAL HEALTH.DEPARTMENT
<br /> $E�u'GE REQuE$T
<br /> 1� rte., �;,.
<br /> Type of Business or Property T FACILITY ID# SERVICE REQUEST#
<br /> 11
<br /> i, �.
<br /> OWNER/OPERATOR
<br /> I' - CHECK ifBiLLINGADDRESS
<br /> 1
<br /> FAQ li ITYAME /�' j'
<br /> ,��,�,,,""""i"!" -,-, -� , , -Amz,gs , ,,,, ,,��,,'.l�"I I I :::�, -,"-,--,,- , ,
<br /> �SITEADDRESS i` 11 ,,,, ,,,", -��,,,-: -,- � ,","I", , I ,,,'��,wI , , ,, ,, . 1�� I w-
<br /> «Strae[Number ,-D(rectlon . =w",��. S eetNam6 - CI Zi C de..
<br /> 1-1�FIOME Or MAILING Ab11
<br /> D_l (If Different fraxm Site Address)
<br /> �� z r � Stteet Number'- Str®at Name
<br /> s �r
<br /> T Y STATE ZIP
<br /> h.,.1::
<br /> PHONE#1 T APN# LAND iJSE APPLICATION# I 11
<br /> 3 3
<br /> !T 't W-latq�P,!Zi'-11'-i l�"I'l�'ll,�,��ll,�"I","-,�,,�--l'-�-11"-"'I'l-�"r"-�""""�"I-I�,"'I'll'-�"""--��,�-I
<br /> PHONE#2 ` -T i I 11 BOS DISTRICT LOCATION CODE
<br /> (� �.,
<br /> „�r,- C,,, TOR/ $ERVICE REQUE$
<br /> REQUESTOR `y ' ` `
<br /> Gam'. CHECK if BILLING ADDRES- ,;�',,",��,,,,-,�,�,�,�,�,,-,,�,,�,,�,�',-��,-","-"-,�'---"�,"�,--1��_'_,,--,,,L'LLLL�-��,�,,,,-,�,,,��,�""","","�F,"",�'-',,;"��,','-�,;-��',�
<br /> Ys LrIt"
<br /> Yi
<br /> t y1.
<br /> 1.
<br /> ;` 'BUSINESS NAME + `' `� '� �/"' PHONE/#_ _ aY s
<br /> '*.., F.z�`arn�a,u_ „�x:,..r ,•'y _kr..r, c„ g $ F. ; ..' �d- ,�✓" zb - � � S r
<br /> a ss w x FAX#
<br /> OME OrMAILING ADDRESS s'"'
<br /> mss *
<br /> I'll -'�,STATE .a s- k
<br /> ll-
<br /> � `'7 e�-' � �
<br /> '4! was `2. F,r.. ;i,. ..,'a'�; .?,.: ...:F' ��
<br /> 13f�.l.fN At1LEl�E ENT` I;<theundersigned;property or business owner,:operator or au#homed agent`of ame,
<br /> ,_,.g CknO�IVe> a than I�Site3nd/Or COeCt S BCIfiG ENVIRONMENTAL HEALTH.DEPpRTMENThOUf) Chaf�eS BSSOCI8teC1.lNltfltF11S rOeCt'Or
<br /> Y 9 P J
<br /> aettvliy tall ape billed to the or�,my busyness as Itlenttfied on this fomi'
<br /> f aiso,ceifjfy that I h ye prepared this appltcatio t and that the work to be.performetl vnli be done in accordance wi#h1111111,�all SaN JoAQu N `n, _'
<br /> CouNTY Ortlinance Codes,5tandactls{STATE and FEDERAL laws
<br /> i PROPERTY'/�BIJSINESSO lP1ER❑ OPERA OR/$ ER ❑ OTHER AUTHORIZED AGENT I� A j��„e� .�j�
<br /> / ` PL A IS O fhE�81LL%NG PARTY /OOf Of a[Ith017ZatlOn tO SI n jS I e GIYetl a , the
<br /> P 9, 416
<br /> ,
<br /> AItTH(}11 RowfiQN TC?RELEASE INFCkE2MATIQN' When applicable I the owner�;or operator of the propeMy'locatetl at the above11Ar
<br /> s fe address hereb(�authonze t e.release of an'sand,--,----j""'iTesbts`geote`ch0icai.-data andlor`en�ironme11 nfaUste.assessrnent`infoFrria`tion
<br /> tO tfte:SAN,IOAOI)IN COUNTY EIvIRONMENTALzHEALTH DEPARTMENT as SOOn`as It IS available afld at the s-111
<br /> ame time111111,1� II IS prOVidel3 t0 me Or
<br /> my representative
<br /> t Y
<br /> r
<br /> TYPE OF SER11iCE REQUESTED r
<br /> k �+
<br /> I 11,111-.1 `' COMMENTS t:„ � } - ° x
<br /> n
<br /> F6 '-ii
<br /> y - - � e I - - , , - - , - - 1-11* ,
<br /> , , � I , ,I I 11 I I m
<br /> I 11 11ACCEPTED'BY EMPLOYEE#: �DATE:
<br /> ,...;
<br /> ASSIGNED TO EMPLOYEE#: .` DATE: :� I ,1,%,", 9 ,
<br /> gym..
<br /> Date SerViCe COmpieted ;(if already aompletetl) SERVICE,CODE:I I ' PI E
<br /> �,: .a,
<br /> Fee Amount11 Amount Paid Payment Date
<br /> Payment Type Invoice# Check# `Received ay: `
<br /> �.<. v.
<br /> I 11,
<br /> %
<br /> EHD 48-02-025 SR FORM(Golden Rod)%,.
<br /> x/17/08' �� .
<br />
|