Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> cnkrovm g 00 7a-?8 <br /> OWNER/OPERATOR <br /> C CHECK If BILLING ADDRESS <br /> FACILITY NAME s/ <br /> �uS+Dm n <br /> SITE ADDRESS I S (� ��O�( �y- (� �1 �G rS q o <br /> Str N tuber J 1 1-- vfr (� <br /> city <br /> HOME Or MAIUNG ADDRESS (If Different from Site Address) Oki 1 1 l 1i e(, 11 P-.-} SC60 <br /> Street Number 1� Ir1�GFs�treetNameV +� <br /> CITY S-T0�-(x_"n STATE ZIP 7,6CA <br /> PHONE#1 ,EXT• APN# LAND USE APPLICATION# <br /> (U % d 1I-�). Wc"1" - <br /> PHONE#2 EXT- BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ONE — ExT. <br /> HOME or MAILING ADDRESS r' FAX# <br /> 1t A 1,14 S 250 ( ) <br /> CITY STATECA ZIP <br /> III G-ZO <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 <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,Standard ,STATE andDE laws. <br /> APPLICANT'S SIGNATURE: DATE: 412 I <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAG OTHER AUTHORIZED AGENT❑ <br /> If APPL/CANT is not the BILGING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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. <br /> TYPE OF SERVICE REQUESTED: r <br /> COMMENTS: <br /> 1 2017 <br /> SAN JOAQUINC o A`4N <br /> ENVIROr4M� <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Z EMPLOYEE#: DATE: .-'aj- <br /> ASSIGNED TO: ti I —L EMPLOYEE#: DATE: L/- J <br /> Date Service Completed (if already completed): SERVICE CODE: �j ' PIE: ) <br /> Fee Amount: z�CGiJ Amount Paid 1 3 C, v Payment Date (,I <br /> Payment Type G L Invoice# Check# 17J:Z Received By: 7 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />