Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST—j— .� <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> PJ ar' 7i phi 62®073-7- y� <br /> OWNER I OPERATOR ` CHECK If BILLING ADDRESS L7 <br /> Rat h Club Cor r +' on �tnc wv�o EQrs <br /> FACILITY NAME <br /> SITE ADDRESS 1L cc I ��Q�,� �S3 7� <br /> l Street Number Direction 4 ` {h Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Aadress) <br /> -50-p �ft SuV�r Ise L} Street Number Street Name <br /> CITYSTATE ZIP <br /> '�--o'c c.(3�- q5 3- <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (zoo) 83� 67o( <br /> PHONE ICI ExT BOS DISTRICT LOCATION CODE <br /> (-meq ) S 3`l-2olD <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> S1Cl J�W n� C-- ��C CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE If E'er <br /> q* � l � S C��� 7pn) S3� 5-101 <br /> HOME or MAILING ADDRESS FAX# <br /> y q E 1 ) <br /> CITY -�N 0.0 STATE G0_ ZIP Q S 3 <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. <br /> APPLICANT'S SIGNATURE: 2�&� ' &a&— DATE: L <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY 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 environmentallsite 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: PAYMENT <br /> COMMENTS: <br /> NOV S 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 'le 8 <br /> ASSIGNEDTO: EMPLOYEE#: DATE: et <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: d Z <br /> Fee Amount: °' Amount Paid D p Payment Date ps <br /> Payment Type C �. S Invoice# Check# Received By: N C75– <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />