Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> T�;e of Business or Property FACILITY ID# SERVICE REQUEST# <br /> au YJ 5g-0679�,--2- <br /> OWNER/OPERATOR <br /> n. T (/ � CHECK If BILLING ADDRESS <br /> FACILITY NAME �C ` J <br /> ���R 3't a r1 Gc c y+�� <br /> Silf,ADDRESS V C CJ r t� 40 <br /> /0 Street Number Direction Street Name Cit Zi Code <br /> �. <br /> HOME Or MAILING ADDRESS (If Different from Site Address) (t '�.( <br /> Street Number Street Name <br /> CITYr l./ TATE ZIP <br /> C 0 - <br /> P� -1' ExT. qpN# !�.^ / LAND USE APPLICATION#F <br /> a7 S- �� s .� �, C/ OCoC a XU <br /> P NE#2 ExT. BOS DISTRICT LOCATION CODE <br /> X <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO CHECK if BILLING ADDRESS <br /> BUSINESS NAME � d I �I� ]_� P EXT. <br /> HOME or M—�I ING ADDRESS o ` / FAX# <br /> / Q u Y t4 ( ) t___`— Cl <br /> CITY /(' ( ?ATE ZIP 'x) <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or businessowner, 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 applicati nd that t 'Work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STA F WS. <br /> APPLICANT'S SIGNATURE: DATE: � �l/5—�20/ 8^ <br /> PROPERTY/BUSINESS OWNER OPERAT / NAGER OTHER AUTHORIZED AGENT ElIf APPLICANT is not t ILL <br /> ING PA 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It Isptj Ped to me or <br /> my representative. )I <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: , <br /> IryaFpM�H�h <br /> ,yRrM� 1y <br /> ACCEPTED BY: L 7" EMPLOYEE#: DATE: G7_ <br /> ASSIGNED TO: l/ EMPLOYEE#: DATE: /C�. <br /> Date Service Completed (if Aready completed): SERVICE CODE: PIE: APO <br /> Fee Amount: �� Amount Paid CJz:) Payment Date <br /> Payment Type Invoice# Check# /b� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />