Laserfiche WebLink
RAN-11AAC1 COUNTY Elf RONMENTAL HEALTH 4ARTMENTRECENEE <br />SERVICE REQUEST <br />Type of Business or Prol*Ay FACILITY ID # <br />L L- <br />QWNER I OPERATOR <br />FACILITY NAME <br />eek) <br />SITE AoORESS -� Aoc--sO N <br />2,O1 1E. steelo mime <br />HOME Or MAILING ADDRESS (if Different from Site Add(08S) <br />CITY <br />�14 <br />J <br />RVICE REOOW <br />.77 6�VI RO N1 TAL <br />CliECK <br />C& . <br />Almee <br />STATE ZIP <br />PHONE #1 EKT, APN9 <br />-._...._... .....,._ _ .� LAND (ISE APPUCATION # <br />P HONE #2 Icxr. 150P DISTRIGO pT J CARE <br />4 } c) <br />[''nNTR ArTOR I SER.VI+CE RMUESTOR <br />1WLLI,N4 . G�1s p(MLEQQ0 : I, the undersigned proporl: or business,owner, at►erafisr or euthnrizetl agent of same, <br />acknowledge that all site andlof projed specific ENVIRONMIZP'T4 HEALTH DpPAftTmgNT hourly charges associated with this project or <br />activity will be billed to me or my business as Identifwd on this form. <br />1 also cartify that I have prepared th . ion and }hat the vmrk to be performed will be done in apoofdanCe with all SAN JOAQUIN <br />COUNTY 00nance Godes, afds, STAre an M laws - <br />APPLICANT'S SIG LIRE: �1 DATE: <br />PROPERTY 1 i3tlSIN6S$ OWNER r QF'ERA ISR ANAQt R I,.i t]TTtEtt AyTHtjRIREp Af4ENT���tS��L <br />if APPLICANT is not the B ry proof of euthorizetlon tq sign is regsl" Title <br />AUTHORIZATI N TO F • When applicable, 1, the owner or operator of the property located at the above <br />skteaddress, hereby authorize the release a ny and all rwults, peate�tlticaal data and/or $nulronmeMallsite assessment information <br />to the SAN JOAaUIN COUNTY ENVIRONMVNTAkL HEALTH NPARTMEN•T as soon @& It is available and at the same time it is provided to me or <br />my representative. l- <br />PAYMENT - <br />TYPE OF SER2vICE REQUESTED: �,t S"�• � � i T <br />AUG 0 9 2013 <br />SAN JOAOUIN COUNTY <br />ENV'JJ10M, ENTAL <br />HEALTH [-PARTMENT <br />Atom, E, D BY: i r fi �' I-wLOYEE #: DATE: <br />AssioNsG TO: ly KOYEE #: DATE: <br />Date Service Completed (if already completed): St vtcECptiE: ( Ct PIE: <br />Fee Amount: 3 ` exp ams�utit Pant payment Date F" 13 <br />Payment Type SA- Invoice # )IA- Received Qy: <br />EHO 48-92-025 SR FORM (Golden Rpd) <br />97(17!88 <br />