Laserfiche WebLink
SAN JOAQU OUNTY ENVIRONMENTAL HEALTH'ab" ENT <br /> SERVICE REQUEST INPARTM <br /> Type of Business or Properly FACILITY ID# SERVICE REQUEST# <br /> C� Ism 3 17 ei (P II 13 <br /> OWNER/OPERATOR ^ CHECK If BILLING ADDRESS❑ <br /> lA�' <br /> FACILITY NAME t IY ,;�6-1 D S H <br /> SITEADDRESS <br /> Street Number LMCtion Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE V EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REGI IESTOR l P CHECK If BILLING ADDRESS <br /> r V DPS <br /> BUSINESS N E , L PN # t I n_ <br /> HOMt01',NWI.ING ADDJ�E�SjS I ( i )�IJ -A "] � r <br /> CITY C VL. STATE ZIP '1J <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 this form. <br /> I also certify that I have prepared this applicati n; d th th work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE ED <br /> APPLICANT'S SIGNATURE:r— DATE: D <br /> PROPERTY/BUSINESS OWNER❑ OPE TO -IMANA R OTHER AUTHORIZED AGENT <br /> 7fAPPLiCANT is not the B/L NG PARTY P oof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATI N: 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 environmentaVsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHDEPARTMENTas soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: r2Q., r0 <br /> COMMENTS: RECEIVED <br /> OCT - 4 2010 <br /> SAN JOAQUIN COUNTY <br /> NVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: U�/� EMPLOYEE#: L�l DATE: I G <br /> -/ <br /> ASSIGNED TO: U/1 EMPLOYEE#: 3/ DATE: L U ( Wv <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: Zd, <br /> A <br /> Fee Amount: -s " �8& Amount Paid 3 b l Payment Datr 6 q 11olV <br /> Payment Type I/ Invoice# Check# 'L 1-1 p Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />