Laserfiche WebLink
3A1N JOAQUIN k-,UUN'I'Y.LI N VIKOiNIVIEN"1'AL tREALl'lI PARZTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ✓EfV/cNG.E �pl}S .�T'd/e,c�' - _ Q► a. <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> I- & ❑ <br /> FACILITY NAME xr <br /> SITE ADDRESS4!0 2 7 1�1 Ill G STK To/�1 95 Zo7 <br /> Street Number Dlrectiort Street Name city Zlo Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• 130S DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ <br /> /+ CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT• <br /> 7w 7,z-1- 41 zo <br /> HOME or MAILING ADDRESS FAX# <br /> /05 CAvPoD G✓kY Svir� G <br /> (740 )72t- *Zo <br /> CITY ©GES( Z STATE CA ZIP 9 2-06+ <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agentof same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> 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,ST RAL law <br /> APPLICANT'S SIGNA 6���j, DATE: r/9/a 7- <br /> PROPERTY/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Tc-/- <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 same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: PAYMENT <br /> RECEIVED <br /> JUL 092002 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> FNVIR0NMFNX4l-HFALTH 01V190N <br /> APPROVED BY: /1.I.,. ,v EMPLOYEE#: �„`Z 'L DATE: .- <br /> ASSIGNED TO: EMPLOYEE#: S DATE: "7— <br /> Y�. <br /> Date Service Completed (if already completed): SERVICE CODE: q'-Ig P1E c^ Lam; <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type ! Invoice# Check# Received By: '- <br /> N <br /> EHD 48-01-025 ` SERVICE REQUEST40RM <br /> REVISED 6-5-02 <br /> w <br />