Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ' <br />` SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Tl-,e r- /z1� Sg C6 7105 C j <br /> OWNER I O ERATOR <br /> n' d - CHECK if BILLING ADDRESS <br /> KJ � <br /> FACILITY 11IAMEY` <br /> SITE ADDRESS �� A G SJU <br /> i �b �� Street Number pirection Street Name /Vi- Gt Zip Code <br /> HOME Or MAILIN(s ADDRESS (If Different from Site Address) <br /> .Street Number Street Name <br /> s. CITY STATE ZIP <br /> 95ri <br /> PHONE#1 EXT- APN# - LAND 115E APPLICATION# <br /> PHONE#2 EXT, 'x BOS DISTRICT LOCATION CODE <br /> a <br /> ( ) <br /> I CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> /� CHECK if BILLING ADDRESS <br /> J . <br /> BUSINESS NAME p�-� PH NE# E`T' <br /> 7! 12/ c T 09 (�L7 //o <br /> HOME or MAILING ADDRESS FAX# <br /> 0 X <br /> CITY 7— <br /> p,4 C- r STATE ZVp /-7 y <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 application and that the work to be performed will be done in accordance vrith all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDE laws. <br /> APPLICANT'S SIGNATURE: DATE:a�n//, R� <br /> PROPERTY I BUSINESS OWNER OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT" <br /> IfAPPucANT is not the BILLING DARTY:proof of authorization to sign is required Title - <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the prop located at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/s' Information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT aS soon as it is available and at the same r r <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: U CI ��" I R 0 <br /> COMMENTS: t1vti//RQ <br /> T l 254L <br /> PERM 4 R, <br /> i//OES <br /> ACCEPTED BY: EMPLOYEE#: DATE: /,�_ l-7 <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (If already Completed): SERVICE CODE', �', "I PIE: I{c A <br /> Fee Amount: �� Amount Paid Payment Date I/-7 <br /> Payment Type l ry" Invoice# Check# Received By: <br /> a <br /> _ v " v r�.��v / rte, 1A)o l�1 <br /> 077/1117/1008 S <br /> 02-025 - f r U rn SR FORM(Golden Rod) <br /> { <br />