Laserfiche WebLink
SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> z'Za <br /> OWNER If OPERA OR <br /> CHECK If BILLING ADDRESS <br /> W C he e. <br /> a <br /> FACILITY E <br /> SITE ADDRESS <br /> b W '2— Slreel Number Direction F� Q Street Namev l Yr [ � city ✓� Zip Code <br /> HOME Or MAILING= (If Different from Site Address) <br /> Dp'� Q�y\Q I �{�C Street Number Street Name <br /> CITY�I U � n ST� ZIP <br /> PHONEA 'C Exr. APN# LAND USE APPLICATION# l <br /> ( 7-eq -$-t$ -G`l21 0-1 L 2-7 0) l <br /> PHO,NEQ#2 ExT• BOS DISTRICT LOCATION CODE <br /> l l lV <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> W at <br /> h �� ` C CHECK If BILLING ADDRESS <br /> BUSINESS NAM K cf �] PHONE# ExT' <br /> t (fir 5 `L,2 � 2 'A1G .- '�I�fo <br /> HOME Or MAILING ADDRESS FAX# <br /> pp L1 0('r� L-aVle ( ) <br /> CITY ^ � STATE ZIP <br /> BILLING A-CdKTJOWLEDGEMENT: 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,ST F and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: S- [(S(I H <br /> PROPERTY/BUSINESS OWNER LJ OPERATOR I MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization f0 Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 prOVlded tQ me or <br /> my representative. /7 <br /> TYPE OF SERVICE REQUESTED: 02— FUVG CM'3 'SVV F 'FHr <br /> COMMENTS: Clyl n0DVW ` yF"wTC• �UAM18 ZO <br /> I <br /> OFCO, <br /> 7-Y <br /> p�T <br /> / �r M T <br /> ACCEPTED BY: �I mw-Dpq EMPLOYEE DATE: (P-1$_IY <br /> ASSIGNED TO: 'MI EMPLOYEE#: DATE: 1 —' <br /> Date Service Completed (if already cDmpleted): SERVICE CODE: PIE: I1p0�1 <br /> Fee Amount: `(�' D Amount Paid 1 ,5a, DID Payment Date / G. <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> S <br />