Laserfiche WebLink
SAN JOAQU COUNTY ENVIRONMENTAL HEALTi ,EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />a i 0-- <br />FACILITY ID # <br />27 g 7 <br />SERVICE REQUEST <br />Steo <br /># <br />OWNER / OPERATQR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME iyi i <br />e 1 <br />i /330 Pia <br />SITE ADDRESS <br />c'?1-1 Street Number Direction AlA VI pE_ , Street Name akier -51 City <br />?.6( <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE. #1 Exr. APN # LAND USE APPLICATION # <br />PHONE #2 En. <br />() t Y\ <br />k DISTRICT MI' NS ..)17, <br />LOCATION CODE <br />CONTRACTd&I kfi10E'RE ESTOR <br />REQUESTOR L ....- <br />a /5 „ ne gie z__ CHECK if BILLING ADDRESS <br />BUSINESS NAME /.. prt )))1e,r , loo/ 5 )d pwr,N , (Z?) 000-1 37 <br />Da <br />HOME or MAILING ADDRESS 5420 <br />5// <br />dv e FAX # , <br />Ht) We - 61 6 / CITY i 11 1)5 e STATE Of/ ZIP 9 c/a. 3 <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 ajd FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT Et <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 DEPART ENT as soon as it is available and at the same time it is <br />provided to me or my representative. Poo ge,,61/9_t e 4- t eleW . <br />TYPE OF SERVICE REQUESTED: V 6 5 COY14pIla-11( <br />I <br />e PPSMEJ\11 <br />V <br />COMMENTS: <br />SPk <br />IA <br />O <br />oiNcl <br />eNV150NppaTIVtEN <br />u N 1 _NCDD <br />DATE <br />: -0:: <br />tik rk -I <br />foif-// 0 <br />oc/eh <br />PI E:a., <br />ACCEPTED BY: 0 c.A. Li.et je4,4 EMPLOYEE #: 10 ,S2j <br />ASSIGNED TO: 7)6_ 0z--,4- EMPLOYEE #: (7.213 <br />Date Service Completed (if already completed): SERVICE CODE: 52_2_ <br />Fee Amount: 5 2 _44. 07) Amount Paid 4 — Payment Date \ 0 jci I 6 <br />Payment Type 1,----- Invoice # Check # Li -7.--4 Received By: cYC,...-- <br />DATE: -5 /0 <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003