Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property _ FACILITY ID# SERVICE REQUEST# <br /> 6tt5 + CoNUr�Ll�i�E k"003 0 SQ. (56:11-P--7C' <br /> WNER I OPERA�TOR,�,. <br /> B'�-5 1 7�LK-\ .JJVG CHECK If BILLING ADDRESSI� <br /> AGILITY NAME <br /> SITE ADDRESS ( S3 k CJ ✓� <br /> StreefNumber plrection ' I ST, TR et K1C� <br /> StreName CI ZI Cotle <br /> OME Or MAILING ADDRESS (If Different from Site Address) �ZS E- C gSTLZ P/JE S <br /> /�' Street Number Street Name <br /> ITY �LjT J1 �- 1 ,A l Q <br /> 1. 'v STATE <br /> PH0NE#1 EXT APN# <br /> (�(�) <br /> 3bq- <br /> , �O� LAND USE APPLICATION# <br /> H a 233 - <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> O ( f It <br /> CONTRACTOR/SERVICE REQUESTOR <br /> norMAILINGADDRESS <br /> CHECK If BILLING ADDRESS <br /> PHONE# EXT. <br /> C FAX# <br /> STATE Zip <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this applicati at the work to,4e performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STAT nd FED L laws. <br /> APPLICANT'S SIGNATURE: 4L DATE: <br /> PROPERTY/BUSINESS OWNER 1:01 PERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/6renvironmental/site assessment information <br /> 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 <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Ao <br /> A" lN N'104A �� 20(1`5 <br /> Hit- ulfACOVN <br /> OEpgq�"1 TY <br /> ACCEPTED BY: t y-r_ ^ EMPLOYEE#: DATE, t <br /> ASSIGNED TO: �V Fr—` EMPLOYEE#: DATE: <br /> Date Service Completed (if already com ted): SERVICE CODE: 0 6 I PIF. <br /> Fee Amount: n Amount Pai '30'l) Payment Date /S 7 <br /> Payment Type 6 6 Invoice# C 1J) Received By: <br /> EHD 48-02-025 <br /> 07/17/08 SR FORM(Golden Rod) <br /> r <br />