Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL REALTREPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />SERVICEEQUEST # <br />,'0A <br />PHONE# <br />r//b cl.111 <br />ExT. <br />E .2 ' <br />3�3 Z <br />DATEV MENT <br />�'C� <br />c S r o ir- <br />c,)c1 (coy.. bt'- <br />S,;, Tc. i 7 <br />(%/h) Cil <br />I le <br />OWNER / OPERATOR <br />STATE C0 , ZIP <br />9 sen <br />(i <br />- <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />A <br />Payment Type&jo. t Ca. -Cl <br />Invoice # <br />SITE ADDRESS 7C7C� <br />/L�. <br />�� J ��C i`CICC; Sr <br />"Sf- )CkrI-Z <br />T Z/C7 <br />Street Number <br />Direction <br />Street Name <br />Ci <br />Zip Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />A/ A <br />Street Number <br />Street N <br />CITY <br />STATE '9 C� �/ L _- <br />PHONE #1 EXT• <br />APN # <br />LAND USE APPLICATION # AUG 1 G 2009 <br />Qocj) 9s 7 - -2 9 <br />1- 3,50 - c to <br />PHONE #2 EXT. <br />BOS DISTRICTLNVI Q <br />( ) <br />—SIMITIARVICE"I <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />��l= i 7"G =TC Y�1�ir tn✓ .: <br />COMMENTS: � %l (t P 1 C 1 V T 3 Ca P 11 / , f7 L Qc-" P fk4 e , I t <br />0 tC1 f f) e- -J Vet --dc,- i2coo t 6, I> •ro <br />tC Vee0c f- i!co-t ke<<v: ,t d 'to CF, (✓I plc t P . AUG 1 7 2009 <br />SAN JOAQUIN COUNTY <br />PHONE# <br />r//b cl.111 <br />ExT. <br />E .2 ' <br />HOME or MAILING ADDRESS <br />DATEV MENT <br />FAX # <br />c,)c1 (coy.. bt'- <br />S,;, Tc. i 7 <br />(%/h) Cil <br />1 1'7 <br />CITY CL Cq r"\ C k 4' C. C -Q l �t 7 <br />STATE C0 , ZIP <br />9 sen <br />BILLING ACKNOWLEDGEMENT: I, 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 FIDERAL laws. <br />APPLICANT'S SIGNATURE: /t,;DATE:I% <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 0 S(21—u" C (� <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:(('�� L4 -S'% <br />r��� 7 %= t7T <br />COMMENTS: � %l (t P 1 C 1 V T 3 Ca P 11 / , f7 L Qc-" P fk4 e , I t <br />0 tC1 f f) e- -J Vet --dc,- i2coo t 6, I> •ro <br />tC Vee0c f- i!co-t ke<<v: ,t d 'to CF, (✓I plc t P . AUG 1 7 2009 <br />SAN JOAQUIN COUNTY <br />ACCEPTED BY: Q U£ l j <br />EMPLOYEE #: 032-( <br />DATEV MENT <br />ASSIGNED TO: '6 Ce- L" <br />EMPLOYEE #: LT`�� tO <br />DATE: -011-t 017 <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P / E:U �) <br />Fee Amount: 3'1,S-, 00 <br />Amount Paid = y s �- <br />Payment Date <br />01 1101i <br />Payment Type&jo. t Ca. -Cl <br />Invoice # <br />Check # ,�, A <br />Received By: I <br />Co�n�Ry42b3 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />