Laserfiche WebLink
Date dUA12111N I OUNIY ENVIRONMENTAL11EALTHDEPARTMENT <br /> SERVICE REQUEST <br /> T of Busines IrVope, . �. FACILITY ID# ✓ SERVICE REQUEST# <br /> � - SC7 -2 <br /> OW R/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 1 / „/t-7!/, <br /> /ern I/t�CY�]V/ Jl <br /> Street Number Direction l,��r/ / i� $' a me City Code <br /> HOME or MAILING ADORES f D' ere fr S'te Address <br /> /7 Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> PHONE#2En, BOS DISTRICT LOCATION CODE <br /> ( l l) 3 (r, <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 <br /> CHECK If BILLING ADDRESS L.0 <br /> BUSINESS NAME PHONE# \\ <br /> 3, <br /> HOME or MAILING ADDRESS FAX# <br /> �) lJ i otyi ) <br /> Cm ] STATE ZIP <br /> BILLING ACKNOWLEDGE NT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE d FEDE�tRALglaws. A G <br /> APPLICANT'S SIGNATURE:Standards, <br /> I�J DATE: �_ 10I •ZLS�f <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ J <br /> IfAPPL1CANTis not the B1LL1NGPAkTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JoAQuiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: L(-$T ! j71' p1 t T f'gYi�� <br /> COMMENTS: �D <br /> JUN 18 2007 <br /> HEgLH p NME CO <br /> m1 <br /> EPApre,,.._ <br /> ACCEPTED BY: .[ �(,�V�rQ EMPLOYEE M &3z( DATE: 74VC) <br /> ASSIGNED TO: / EMPLOYEE M 02(0'7 U DATE: c`1_ 0 <br /> Date Service Completed (if already completed): SERVICE CODE: Q�' P 1E: -7 SOS) <br /> Fee Amount: �7e Amount Paid o2 V�— payment Date <br /> Payment TyOVOIce# Check# Recei <br /> 3v <br /> �ed By: <br /> EHD 48-02-025 FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />