Laserfiche WebLink
IFICUMVC!. <br /> SAN JOAQUIN'19NTY ENVIRONMENTAL HEALTH IORTMENT JAN 04 2010 <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY ID# SERVICE RE 6 " N T zl <br /> unvgeld:cc_ 6T61Lt y G 5 _ FA C) <br /> Lf(459067396 <br /> OWNER/OPERAT—OR / <br /> (±S -(— ix� Tn ` C �'),1 t �� // CHECK If BILLING ADDRESS <br /> FACILITY NAME JJ^^ <br /> F4'5— ���� � CA £L) 11-V-1 <br /> $ITEAPRESS <br /> /0�� <br /> Street Number Direction Street Name Ci <br /> ti <br /> Zf Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> R.. _ T <br /> PHONE#1 Err. APN# LAND USE APPLICATION# r�t� CS Q <br /> 1 ( 1vM 0? 16 <br /> PHONE#2 En. SOS DISTRICT LOC MEC <br /> t11 DE�NTq <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR / <br /> .,�/ {�✓'�!� a, tly� <br /> BUSINESS NAME PHONE# CHECK if BILLING ADDRESS <br /> �' <br /> / <br /> HOME or MAILING ADDRESS <br /> //,, FAX# <br /> CITY <br /> �VL 1M &,q - hST,FATE ZIP �P <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 <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 work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,StandASTAERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: I,2-- % — /-J—PROPERTY/BUSINESS OWNER❑ MANAGER ❑ OTHER AUTHORIZED AGENT ASIC r�-rIf APPLICANT is noTY 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: <br /> COMMENTS: (N1 h I *kte JS G j ,y /1 ��7 t DL%ct g 1L. L� T (✓' <br /> IZi lvtc � rn tiT, p J S , V)SGiL <br /> / £ST ✓ � � L rJ ;Lr7ci� %/✓!L �� 4v/ /Jtero <br /> IZ2r / ,CL mSPL <br /> ACCEPTED BY: EMPLOYEE M DATE: Q) 1 <br /> ASSIGNED TO: ri EMPLOYEE#: DATE: ©, <br /> Date Service Completed (if already completed): SERVICE CODE: Gh� p/E;/L2 <br /> Fee Amount: 310_ Amount P d 15 Payment Date J <br /> Payment Type Invoice# Check# <br /> d�S�. R calved By:� <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />