Laserfiche WebLink
SAN JOAQUINv UN'I'Y ENVIRONMF,N"TAL.HEAI:FH I) t AR'I'Mi�INT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 OPERATOR ® I <br /> ICHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 37 G1 Y G n L6,<2R7/ <br /> - /2 v( ^0 L L q5 3 7 4- <br /> Street Number Direction Street Name City Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APFI# LAND USE APPLICATION# <br /> ( ) .2-t Lf-oz-v --t 7 <br /> PHONE#2 EXT. BOS DISTRICT CATION CODE <br /> CONTRACTOR / SERVICE REQUES'TOR <br /> REQUEST OR <br /> CHECK If BILLING ADDRESS LA- <br /> N <br /> A. <br /> -�Sti tit <br /> BUSINESS PVA,M / PHONE# EXT. <br /> ( Zor) <br /> HOME or MAILING ADDRESS FAX# <br /> ///y a,Irt . 44,.c 701 3 7-) (Z,&� 3 J' -I'SL[3 <br /> CITY <br /> 1-4-a4 &.4- <br /> STATE ZIP5,f ZLt U i <br /> BILLING A(:LCNOWL.EDGEMENT: 1, the undersigned property or business owner, operator orauthorized agent of sante, <br /> acknowl:xige that all site and/or project specific ENVIRONMBNTAI.HI?Al;l'lI DEPARTMENT hourly charges associated with this project <br /> or activity will be milled to me or my business as identified on this form. <br /> E also cc:-tify that i have prepared this application and that the work to be performed will be done in accordance with all SAN.IOAWIN <br /> OWN]r Urdinancc('odes,,Standartls,STATv and FI?DI?RAI, laws. <br /> AI'E'@_.Ef'AN'I''S SIGNATURE: — _ DATE: <br /> hROI'E{K'I!'/BUSINFSOWNER❑ OPERATOR MANAGER ❑ Q)I'riwizAirrimiuz.mAcENT❑ <br /> ij',f/'P1,1CANT is not the BILLING i X TY,proof of'authorization to sign is required Title <br /> AlITI[WRIZA"TION TO RELEASE INFORMA'rLON: 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(OUNTY ENVIRONMENTAL HEALTH Di;PARTIVII:NT assoon as it is available and at the sante time it is <br /> provide(:to me or my representative. <br /> TYPE OF SERVICEREO.UESTED: 7)&DF(T D r R y I�✓Ora <br /> COMMENT: JUN 1 1 2010 <br /> JUN 1 1 20M <br /> n, p S(�AN JOAQUIN COUNTY <br /> ENVIRONPOENT HEALTI�ALTH DEPARTMENT <br /> FERMIT/SERMES <br /> ACCEPTED BY: ©L i U i ✓Q.AC EMPLOYEE#: 03 Z4 DATE: [fit <br /> r 1 p <br /> ASSIGNED TO: n(%.)E_p A EMPLOYEE#: 14;—, 1 DATE: (t [E) <br /> Date Service Completed (if already completed): SERVICE CODE: rQ PIE:` 2-3o <br /> Fee Amount: J 4S Paid 3 It S _ Payment Date l <br /> Payment Type �j Invoice# Check# \SLk g Recei ed y: �(r <br /> EHD 48-G2 025 SR FORM(Golden Rodadf <br /> REVISEL:11/17/200,2 <br />