Laserfiche WebLink
SAN JOA(, COUNTY ENVIRONMENTAL HEAL'. EPARTMENT <br /> SERVICE;REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if B ING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 3r�la� �� 3.i <br /> Street Number Direction Street Name Zip Cod <br /> HOME or MAILING ADDRES711ifferent from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLI ATION# <br /> 0 70 3-v <br /> PHONE#2 EXT. B DISTRI LOCATION�CODE <br /> ( <br /> CONTRACTOR / S RVICE RE TOR <br /> QUESTOR <br /> CHECK if BILLIN DDRESS <br /> BUSINESS NAME �tlJ� 1 P EXT. <br /> A Y [303 F <br /> HOME or MAILING ADDRESS FAX# <br /> (qo� <br /> CITY ��c:"t STATE CLT ZIP p Sl <br /> BILLING A KNOWLED MENT: 1, the u ersigned property or business owner, o rator or authorized agent of same, <br /> acknowledge hat all site and/ project specific NVIRONMENTAL HEALTH DEPARTMENT rly charges associated with this project <br /> or activity will be billed to me o my business identified on this forn1. <br /> 1 also certify th t 1 have prepared t tion and that the work to be performed ill be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordina ce Codes,Standards, STATE- and FEDER.,ALI laws. <br /> PPLICANT'S GNATURE: Gc- t,u- U /`-C DATE: i 1 J�o�' <br /> PRO TY/BUSINES OWNER❑ OPERATOR/MANAGER ❑ OT AUTHORIZED AGENT 0 w <br /> IfAP ICANT is 1701 the BILLING PARTY,proof of author' ation to sign is required !le <br /> AUTHORI ]ON O RELEASE INFORMATION: When a licable, 1,the owner or operator of the ropert),located at the <br /> above site addr he by authorize the release of any and 1 results, geotechnical data and/or env' onmental/site assessment <br /> information to the S J QUIN COUNTY ENVIRONMENTAL ALTH DEPARTMENT as soon as it is avail le and at the same time it is <br /> provided to me or my rep ntative. ti <br /> TYPE OF SERVICE REQUESTED: 5 j ✓ d �'{' pP� `J CCI ) I� t��� <br /> COMMENTS: <br /> 2 200 (dull 4 2008 <br /> SAN JOAQUIN C NN <br /> ENVIRON TAL FNVIRC►Ni!�EN HEALTH <br /> HEALTH DF ARTMEN� PER(,/IiT/SERVICF_5 <br /> ACCEPTED BY: A EMPLOY #: DATE: 2 I C f- <br /> ASSIGNED TO: V C ^i Lt LtEMP YEE#: e3 1-7 DATE: 11 2(4 C, ., <br /> Date Service Complete (if already completed): SERVICE CODE: K PIE: <br /> 23c <br /> Fee Amount: i 5 L-L, Amount Paid 5 Payment Date <br /> Payment Type Invoice# Check# /l Received By: - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />