Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST • <br /> Type o Busines or property ' FACILITY ID# SERVICE REQUEST# <br /> �dlG 7a3 � s 9�� <br /> OWNE /OPERATOR ' <br /> a//0 Lie, <br /> " CHECK If BILLING ADDRESS <br /> FACILITY NAME g' DICn <br /> SITE ADDRESS 2S5•U ( (\JAI , 11, 1V qq jam' can so r <br /> J Street Number Direction f�W1 _I Street Naine V„� `� • city Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site A dress) <br /> /9 KA Flzaj,AStreet Number Street Name <br /> CIN STAT ZIP <br /> PHONE#t E APN# I ( r LAND USE APPLICATION# <br /> I/11 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> iP7) 9 -9U/a -a <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PNO 1 EXT*HOME Or MAILING ADDRESS FA2x# <br /> CITY STATE ZIP -qi o <br /> BILLING ACKNOWLEDGEM T: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENvfRONMENTAL HEALTH DEPARTMENT hourly charges associated with this projector <br /> activity will be billed to me or my business as identified on this form <br /> I also certify that I have prepared this applic on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA ant}FEDERAL laws. <br /> / <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT �G <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is require Titl e <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 environmental/site assessment <br /> information to the SAN JOAQURN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: (t_S T— F /'j PAYMENT <br /> COMMENTS: <br /> SEP 17 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: oL, tV I .O st EMPLOYEE#: 3-Zr DATE: !D -7 (C <br /> ASSIGNEDTO: V O f LL-(, E EMPLOYEE#: 0 3 (7 DATE: [ /17107 <br /> Q^ <br /> Date Service Completed (if already completed): SERVICE CODE: o J P 1 E: <br /> Fee Amount: �LC7 Amount Paid ��c/ Payment Date �—� (0-7 <br /> Payment Type ✓ Invoice# Check# 2tiSg Received By: <br /> EHD 48-02-025 ' ,SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />