Laserfiche WebLink
SAN JOAQUIIC'COUNTY ENVIRONMENTAL HEALTAPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Nci 1 <br />FACILITY ID # <br />L <br />RU YME T <br />A 2009 <br />SAN JO ONIME� <br />SERVICE REQUEST # <br />Gaol ne ofspen5 i r%q <br />3,73 c% <br />CITY�^-01 t <br />-512 0 0,:5-& 7.3 7 <br />Ow ER / OPERATOR <br />Va lem r=...e f� p • <br />DATE: �3/ --le c^ <br />CHECK If BILLING ADDRESS <br /># <br />FACILITY NAME Valerol <br />1/ <br />V��µamt�ne� <br />P / E: 3c <br />SITE ADDRESS <br />��l O <br />I <br />Lat1e, <br />Payment Date 2 lj <br />�j-�& �I.+on <br />gSZID <br />Street Number <br />Direction <br />Street Name <br />Ci <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />SCN <br />CITY <br />TA M%WIP <br />PHONE #1 EXT. <br />( ► <br />APN # <br />0c 2 <br />LAND USE APPLICATION # <br />PHONE #2 EXT <br />BOS DISTRICT <br />AT CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />?-Zi j-2 & f 2 r4 nb <br />CHECK if BILLING ADDRESS <br />BUSINESS NAMEPHONE <br />:5bn+ec1 <br />L <br />RU YME T <br />A 2009 <br />SAN JO ONIME� <br /># ExT. <br />707 765- 1460 lD� <br />HOME or MAILING ADDRESS I U LI` <br />FAX # <br />('701) 7&5- 9108 <br />CITY�^-01 t <br />STATE Ga ZIP 4K454 <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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: (� 1✓"^' on 661E dl Qlpb&M(k0m. DATE: 3�1b�o9 /� L- p,{ <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT El &jtntyfor AI F63 r 61fi)leo <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: <br />RUSH <br />L <br />RU YME T <br />A 2009 <br />SAN JO ONIME� <br />ACCEPTED BY: L L. t U E d_ <br />T <br />EMPLOYEE #: >. j z <br />DATE: 4y" Z C• <br />ASSIGNED TO: A C. (� u � <br />EMPLOYEE #: S &, <br />DATE: �3/ --le c^ <br />Date Service Completed (if already completed): <br />SERVICE CODE l c03l <br />P / E: 3c <br />Fee Amount: _4 '+-7 2-5 v <br />Amount Paid <br />4 <br />Payment Date 2 lj <br />Payment Type v <br />Invoice # <br />Check # 3 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />TY <br />NT <br />