Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FFAclLrryNAME <br /> of Business or Property FACILITY ID# �ICE�REQUE�,#� <br /> it �� ��tbv a <br /> ER/OPERATOR <br /> �O -1� U KO S K ' CHECK If BILLING ADDRESS O <br /> 71 �, n C 1 ,� M I D D I F ART&- . le y/-oo t_ <br /> SITEADDRESS T/1tbrls" E. Mtkc � 1 �F ���_�v 9S��0 <br /> Street Number Direct{on Street Name Ci Zi CoEe <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> street Number Street Name <br /> CITY STATE Zip <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> (2Oq ) �o i q a� o g <br /> PHONE#2 EXT. BOB DISTRICT LOCATION CODE <br /> ( ) © � 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> R11 ff-&--L C-1`6 CHECK If BILLING ADDRESS 01 <br /> BUSINESS NAME -rye I V1q I L E y L FAX NI N& n P S# q q-.�• - f� g 3 EXT <br /> HOME or MAILING ADDRESS # FAX# <br /> �`j01 Stpnl�2luGE 1J1�• fUt7E 2n ( ) <br /> CITY �/ � IS dam, r--rr�N STATE ('� zip <br /> _BILLING <br /> .eACKNOWLEDGEMENT: 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,Standards, ATE and FEDERAL laws. /APPLICANT'S SIGNATURE: DATE: 3,t <br /> PROPERTY/BUSINESS OWNER PERATOR/MANAGER ❑ OTHERAUTn DAGENT Vil-O /PL�rfry C•{„ rlX//Ir•�CIC <br /> IfAPPCICANr is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: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. PAY <br /> TYPE OF SERVICE REouESTED: CEI!/ <br /> ED <br /> COMMENTS: <br /> SAN 1 1016 <br /> EIV <br /> HE &O COU <br /> THR P R SENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: Z- 2- L 16 <br /> ASSIGNED TO: O ��Z EMPLOYEE#: DATE: 3_ 2 A0 J <br /> Date Service Completed ,(if already completed): SERVICE CODE: P 1 E: Z <br /> Fee Amount: Amount P ' 30DD Payment Date `--'21 <br /> Payment Type Invoice# Check# 3 SS Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />