Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S k I~A p 1i3A'tZ C s-rr,<vR N SS -00 7(Q S 10 <br /> OWNER I OPERATOR r��q3 <br /> J C—ss ICA t_v I CHECK if BILLING ADDRESS`l <br /> FACILITY NAME Po Kt` K Q � <br /> SITE ADDRESS W w A r S p <br /> Z I J Street Number Direction 5tree Name `�p Ci �p� ZI�Cade <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Mame <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION 4 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REGIUESTOR <br /> Teile ��i2(��S G�{{Z CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex-r. <br /> HOME.or MAILING ADDRESS FAX# <br /> L <br /> 3 S S- S MAST,t v� ( --t— <br /> s O C A—ro " STATE CA_ ZIP 4152-0 -S <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 charge§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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �, 'q DATE: •y�Z� <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT /� IZG l <br /> IfAPPLicANT 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 environmentallsite assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and <br /> it is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: G <br /> COMMENTS; MCI 8 20 <br /> SAN JOAQUIN COUNTY <br /> EfflnROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Q,�/A DAA �'�U EMPLOYEE M DATE: a <br /> ASSIGNEDTO: ( 1l EMPLOYEE#: DATE: lZ Z(� [(0 <br /> Date Service Completed (if already completed): SERVICE CODE: SC � I PIE: b l <br /> Fee Amount: Amount Paid 7 m fJ Payment Date {;Z g <br /> Payment Type [ Invoice# Check# O G S ! Received By: <br /> v <br /> EH©48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />