Laserfiche WebLink
SAN JOAQUI�t'OUNTY ENVIRONMENTAL HEALTH bl PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �t - jcS s St/ io <br /> OWNER/OPERATQR <br /> CHECK If BILLING ADDRE9913 <br /> W N <br /> FACILITf NAME <br /> C"i-J L K <br /> rIt czDass Cambrl ti JAEbrop 53aa <br /> 6traet Numoar Di Stroet Name C 1 <br /> ZP Cod, <br /> HOME Or MAILING ADDRESS (Ii Different from Site Address) <br /> 9m"t Numaer 9treel Namc <br /> CITY STATE ZJP. <br /> PHONE#1 EHr_ APNNLAND UHE APPLICATION IS <br /> (204 ) 0586. 411x' C '43W _32— <br /> PHONE#2 FST. SO$DsTmcT7 LOCATION CODE <br /> ` r <br /> Fi51 i 270_ Sf 3 J <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I,C srMurce's e *�Y IdoOof (0 -7SSI C1111 BILLING ADwa:SS® <br /> BuslNessNAME1-C Seg.VrLss' sSF# - "7.70 <br /> HOME or MAILING ADDRESS FAx# <br /> z AJr _� 1 ) <br /> CITY Fcra r�n STATE CA ZIP '7?t <br /> BILLING ACKNOWLEDGEMENT: 1, 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 on this form. <br /> I also certify that I have prepared this application and that the w k to be performed will be done in necorda 'th.all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TE nd PEDMi lI s. <br /> APPLICANT'S SIGNATURE: b DATE- <br /> 9- 1-7 -Or <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTNokxztD AGENT <br /> JfAPPLICANT is not the&mJNG PAR proof of authorization to sign is required Ttrta <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 enviromnental/site assessment <br /> information to the SAN JOAQUIN 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: <br /> COMMENTS: <br /> �ENS�p EpRTM� <br /> HEAL-�OE <br /> ACCEPTED BY: (9 C—t t/e I I? EMPLOYEE#: 7J2 DATE: C? r SY <br /> ASSIGNED TO: A)4--(-9Lt EMPLOYEE#: 2-1:7rt) DATE: et ( cf <br /> Data Service Completed (U alinady completed): S[.RVICE CODE: ' 0 PiE: O <br /> Fee Amount7W ---- - <br /> 15:j2/ Amount Paid 5 56 ,00 rt23 0 Q Payment Date ra <br /> Payment Type Invoice# Check# C)y S9 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> Z Id SKIAHS 3� wdla : e 8002 • il • deS <br />