SR0079697 - Laserfiche WebLink

Home Browse Search

■ ■ %M p 26'8, 03:59p River Rats Septic 9167762736 p.1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK if BILLING ADDRESS SERVICE REQUEST # SIL A-, BUSINESS NNAMEnnPHONE# I? % "r✓p 8 201 8 EXT - A d o NZ.0 OWNE OPERATOR SL. CHECK If BILLING ADDRESS [� ACCEPTED BY: FACILITY NAME '? I- 3 SITEAD}D{RESS 25 ASSIGNED TO: `,1 � \4' -' , CITY Street Number tion et Name PIE; �X Fee Amount: }�i� Amount Paid HOME orMAILINGADDRESS (If Different from Site Address) Payment Date '-7- Payment Payment Type�� Invoice # C ck # ✓ Street Number Street Name CITY STATE ZIP PHONE #t 'PN # C� LAND USE APPLICATION # PHONE #2 EXT. ETOS DISTRICT LOCATION CODE 1 ) O 7]r( CONTRACTOR / SERVICE REQUESTOR REQUESQR CHECK if BILLING ADDRESS COMMENTS: BUSINESS NNAMEnnPHONE# I? "r✓p 8 201 8 EXT - A d o NZ.0 '�c; 30 - ) ti M o HO r MAILING ADDRESS � 3 ACCEPTED BY: FAX # '? I- 3 DATE: HjI ASSIGNED TO: 1(z ) -' , CITY STATE ZIP %-0 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIROWENTAL HEALTFi DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. T also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, Si' TE and FEDERAL, laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESSOWNER L OPERATOR/ MANAGF,R ❑ OTHER AUTHORIZED AGENT ❑ If APPLIC INT is not the BILLING PARTY, proof of authorization to sign is required Title ALTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. P% TYPE OF SERVICE REQUESTED: COMMENTS: �t�,c ��,\� ��Llv ��CL6 "r✓p 8 201 8 d o NZ.0 (? uN ACCEPTED BY: EMPLOYEE #: DATE: HjI ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: C, PIE; �X Fee Amount: }�i� Amount Paid /s;,oa Payment Date '-7- Payment Payment Type�� Invoice # C ck # Rece ved By: EHD 48-02-025 SR FORM (Golden Rod) RFVISFD 111117/2003 Received Time Sep.26. 2018 3:49PM No,4181