Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />{{-.�� � dd x <br />17i:EJ t,���lv�l ��'Il��lfl� <br />FACILITY ID # <br />BUSINESS NAME y� <br />� <br />SERVICE REQUEST # <br />PHON1 <br />-J ` �' <br />HOME or MAILING ADD RtaS <br />1 < <br />s .. <br />A <br />OWNER I OPERATOR f <br />-- <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />ZIP <br />SITE ADDRESS <br />' <br />� <br />C� J <br />_3 7 J Street Number <br />134ction <br />` eet Name <br />CI <br />ZI Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />699 <br />PHONE #2 EXT. <br />BOS DISTRICT —7 <br />LOCATION CODE <br />Cj <br />1 <br />CONTRACTO* I a*M,,'*41MVEVf0R <br />REQUESTOR <br />{{-.�� � dd x <br />17i:EJ t,���lv�l ��'Il��lfl� <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME y� <br />� <br />rt -k „ �tISl1�!r <br />`ll �; N <br />PHON1 <br />-J ` �' <br />HOME or MAILING ADD RtaS <br />1 < <br />s .. <br />A <br />/Ax <br />CITY �j//� <br />STATE <br />ZIP <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 />also certify that I have prepared this applicatioln and that the wp to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE/an F laws., <br />APPLICANT'S SIGNATURE: ,L DATE: <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ L <br />It 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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It is provided to me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: 1^ I l 't i 0 l,,,J S 1 L - .J St�}'T T r) n 4 PLI <br />COMMENTS: 0 ^,�A-) JE C� 0 � J Pi?—f) /'" O E—/J SAIV JO%iQtJl <br />F C E1vvlf� /V CCI <br />pOGL F4 s E E L .� U S 7�c S S I NL yEgcrHIC"OE/,,'' <br />q S-3 — -7 (oT7 7 �FD <br />ACCEPTED BY: L t (,j % (" EMPLOYEE #: DATE: -I S <br />ASSIGNED TO: S tw t t b EMPLOYEE M DATE: 4 f S ( <br />Date Service Completed (if already completed): SERVICE CODE: C �; f PI E: Lf Zcy 2– <br />Fee <br />Fee Amount: 13c� Amount Pal Payment Date 1-7 <br />Payment Type Invoice # CheCc/k # 7 5�-'bReceived By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />