Laserfiche WebLink
03/21/2003 09:19 4640138 ENVIRONMENTAL HEALTH PAGE 02 <br /> bAN JVAt1UIJN 11-01x r.NVUtuINIVIH.N't'ALI1CAL1-1-1 LiWtYM6vt �. <br /> SERVICE REQUEST PA0vED <br /> Type of Business or Property FACILITY ID# 2ER1/151JEQUE 33 <br /> �7ASoLIn1 E � Vii 5 nc*] CW 3-77 MAR `4� L <br /> UNC <br /> OWNER( OPERATOR SAN SOF NSE 1V� �0� <br /> pUB�ME� �i�uNs ADORESS <br /> FACILITY NAME Cl p.f 1 I <br /> SITE ADDRESS K� <br /> 231 Street Number Dlrectlon C Street Name _cityZt Ced <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number et Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR i D , <br /> C K—A 1 CHECK If BILLING ADDRESS <br /> ER <br /> BUSINESS NAME ' t i IV PHONE# . EXT. <br /> G1TL - F'- tJC 4 u NS-0 <br /> HOME Or MAILING ADDRESS FAX# <br /> v�� 5 ►9751 5� - 7i S8 <br /> CITY STATE C ZIP q ( - <br /> MLL �1G ACKNOWLEDGEMENT: t, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONML'NTALHEALTH DF,PARTMENT 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,STAT FBDrRA-L s. <br /> APPLICANT'S SIGNATURE: ;0* X- DnrE: <br /> PROPERTY/BUSIN FCS OWN FIX 13 OPERA ORI MANAGER OTHER AUTHORMED AGFrfrA &(Iart t (D12 Sttct�L- 1 <br /> If APPL/CA/JT it not the 811,1,ING ARTY proof of authorization to sign is required Tirfe <br /> AUTHORMATION TO RELEASE INFORMATION: Whcn 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 envirownental/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: Li�j It RECEIVED <br /> COMMENTS: <br /> a� c,�` uAfly �tl��I�uLi,. c `M. �-r rws >�WAR 312003 <br /> 'li15xnrfi� oN /4/03 SAN.IOAQUIN COUNTY <br /> P0F,'1.!C HEALTH SERVICES <br /> EFA1P01Vb1F1,!TN HF )TH INVISOA <br /> APPROVED By: Dom` EMPLOYEE#: �j�� DATE: <br /> ASSIGNED TO: 9 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 'Q.3pS PIE: \�1� <br /> Fee Amount: mount Paid���,5�7L a� Payment Date <br /> �' 24t A <br /> Payment Type ✓ voice# Check# �70AI Received By: <br /> 7-7 <br /> EHD 48-01-025 SERVICE REQUEST FORM <br />