Laserfiche WebLink
SAN JOAQUIN'�"`)UNTY ENVIRONMENTAL HEALTH T EPARTMENT <br /> SERVICE REQUEST "of <br /> Typ Busines r Pro pe 3� s FACILITY ID# SE—T RVICE REQUEST# <br /> 5(200 X08 <br /> OWN I PERATO JJ <br /> V"-1� _ / /7 CHECK if BILLING ADDRESS <br /> t U ,I L/(/rJ/Vt. L/. <br /> FACIUIY NAME .r} y� Q I � �} 7 y�� <br /> SITE DDR � /I J�(/C U SLC CI `750!'I!/ <br /> 5 Street Number Dnection L Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (1 if/f�Trent from Site Address) <br /> V' Street Number Street Name <br /> CITY <br /> STATE ZIP 97.E <br /> LO..' 7 <br /> HONE <br /> PE'T. APN# LAND USE APPLICATION# <br /> (��) 3a -6376 <br /> PH #2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO t <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME t ��j , PHONE_ T' <br /> HOME Or MAILIN ADDRESS w C-.- FAn) Ao I—/^�f J2 <br /> CITY STATE ZIP (`., `1/',,.. <br /> BILLING ACKNOWLE GEMENT: 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 applieption and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S A)rht and fEDEFAL 1 S. �7 <br /> APPLICANT'S SIGNATURE: DATE: /� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Qdele �pe <br /> IfAPPLICANTisnotthe B/LLINGPARTY proof ofauthorization 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: Q �OQQ <br /> tt4 M <br /> H�LTH OEPPP <br /> ACCEPTED BY: EMPLOYEE#: DATE: �r <br /> ASSIGNED TO: S t EMPLOYEE#: X9 DATE: K• <br /> Date Service Completed (if already completed): SERVICE CODE: $ PIE: <br /> Fee Amount: a , ObI <br /> Amount Paid Ip")7 f Payment Date a 'r <br /> Payment Type .i Invoice# - Check# Received By: / <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> - REVISED 11/17/2003 - - <br />