Laserfiche WebLink
SAN JOAQU:. COUNTY ENVIRONMENTAL HEALTh _c,PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVIC EQUEST# <br /> OWNER OPERATOR <br /> j CHECK If BILLING ADDRESS <br /> FACILITY NAME / <br /> ITfStreet <br /> ADDRESS C1 <br /> So umber Direction trees Name city Zip Code <br /> HOME Or MAILING ADDRESS If Different from Site Address) <br /> /Avl /,. <br /> Street Number Street Name <br /> CITY "STATE ZIP <br /> PHONE#1 XT. APN# LAND USE APPLICATION# <br /> QVI ► g - l5-i�o 7 3 - 0 7r) -)� <br /> PHONE#2 EXT. BOS DISTRICT LOCATI N CODE <br /> ( , 2 <br /> CONT CTOR / SERVJLf4LF,.QUESTOR <br /> REQUESTOR Ue�AP-V441X Y <br /> CHECK if BILLING ADDRESSOL <br /> BUSINESS NAME HONE# Ext. <br /> ry - -o, v - 1003 <br /> HOME or MAILING ADDRESSr (�n F(AX# i <br /> 1690 <br /> Qq(W) <br /> do , 2t) — L% zb 0 <br /> CITY ^ O ( STATE ZIP <br /> L/'i � <br /> BILLING ACKNOW GEMENT: I, the un ersighed pro erty or business owner, operator or authorized agent of same, <br /> acknowledge that all site /or project specific E v)kONMENTAL EALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to <br /> or my business as i efitified on this f I <br /> 1 also certify at 1 have pr par d this application and that the work to b 'perfornfed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordi ance Codes, to dards,STATE ark d FEDERAL laws. <br /> APPLICANT' SIGNATURE: // L` xca�,l, DATE: ✓l' ! a J <br /> PROPERTY/BUSI ESS OWNER❑ OPEIYATOR/MANAGER ❑ OTHER Ali ORIZED AGENT e Gr--"p f al-ce �e Y <br /> I <br /> APPLICANT is not the B//B/ LIN ,proof of authorization to sr n is required rule <br /> A HORIZAT N TO RELEASE INFORMATION: When applicable, 1,the caner or operator of the property located at the <br /> above 'te addre s, hereby author'' the release of any and all results, geotech 'cal data and/or environmental/site assessment <br /> informatio SAN JOAQUIN COaNTY ENVIRONMENTAL HEALTH DEPARTMENT as on as it is available and at the same time it is <br /> provided to me or my representativ . (l( .S T AZTW t <br /> TYPE OF SERVICE REQU,E�S�TE�D: �r 1 tl� �`�L�� �� �1 <br /> COMMENTS: Ill LlWC.��S-- �L �jr`u�tiL'LU l7C �1��1 0L+(p�i.Y L1J D <br /> PAYMENT <br /> RECEIVED MAR 2 0 2009 <br /> MAR 2 0 2009 ENONMENT HEALTH <br /> ACCEPTED BY: SAN JOAQUIN C� 1LOYEE#: <br /> cv t v,t: MEI I 3?� 3 G <br /> ASSIGNED TO: 0�� ��K HEALTH MPLOYEE#: 3 ( )ATE: O <br /> Date Service Completed (if already completed): SERVICE CODE: l Q� P I E: <br /> 230e' <br /> Fee Amount: (,� It Ot✓ Amount Paid 3 r Payment Date 3 D 1D 9 <br /> Payment Type / Invoice# Check# Received By: <br /> EHD 48-02-025 SRFORM(Golden Rod) <br /> REVISED 11/17/2003 <br />