Laserfiche WebLink
SAN JOAQICOUNTY ENVIRONMENTAL HEALTH40PARTMENT <br /> SERVICE RE¢UEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR` +r/`' `aj <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME -i��`-c S \�r_ <br /> SITE ADDRESS I r� I C)`e ,� „ 1 a,1A <br /> Street <br /> Numler Direction r�� " ```{J�GS(treet Nea'me J Cit CCJ ` Zi Co�dCe <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE Ill EXT. APN# LAND USE APPLICATION# <br /> ( I <br /> PHONE#2 EXT• 130S DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR 1��V <br /> REQU ESTOR CHECK if BILLING ADDRESS Lr <br /> H <br /> BUSINESS NAME D C �� t p / /, <br /> �7L F ` �� _l L�-� �Y•l W PHONE# ���- WD Exr. <br /> HOME or MAILING ADDRESS/� FAX# <br /> 1 L) CJL��, ( ) <br /> CITY Q q 'S1 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. `� ( �J <br /> APPLICANT'S SIGNATURE: �c�,� tyV , !'U-t.�1,Lt B�ct� DATE: �`�-U t CX�1G 1 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT "C9 ObluJ 1[ al't <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required ki 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/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ALIG 2 8 2011 <br /> Er: _., IAL HEALTH <br /> (��,� ��p� r•tti <br /> ACCEPTED BY: rly� ' " t_f�/- EMPLOYEE#: DAT : I <br /> ASSIGNED TO: Inn Cq v EMPLOYEE#: DATE: 1-7 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: ) <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />