Laserfiche WebLink
SAN JOAQUI_ 'OUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#L SERVICE REQUEST# <br /> C'Li6m( C� 1 l ec(ct o c� S'�r ,- Z—� 52 c)DT? -13 <br /> OWNER/OPERATOR <br /> h( --C) / G CHECK if BILLING ADDRESS <br /> IL <br /> FACILITY NAME <br /> SITE ADDRESS —// / C <br /> t V v Street Number Direction /v Stree�t"Name " �� Cit Zi Code <br /> HOME Or MAI <br /> LING <br /> ADDRESS (If Different from Site Address) Q� /L,/C <br /> /L/• +-��-(- ✓�//s <br /> Street Number )' /1 Svtreet Name? <br /> CITY STATE�� ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# Y <br /> (UIq ) �-5- 133 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 3e—Mw <br /> h1Vt1 r �l/-7a( -� CHECK if BILLING ADDRESS <br /> BUSINESS NAME �-�9-—o1 t �/ / ( �r ExT• <br /> HOME or MAILING ADDRESS 1 �i FAX##1 <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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,STAT and FEDERAL laws. oe <br /> �( �J <br /> APPLICANT'S SIGNATURE: DATE: t/ <br /> PROPERTY/BUSINESS OWNER PE MANAGER El OTHER AUT}IORIZED AGENT ff Ll r L/1lf/Zl Y/lam �E'S I&rt7 <br /> IfAPPLICANT is not the BILLING 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: ( rn,+ JD Q <br /> ECE p " Uk• C I( GS C� DG1't • ��-/"�j �G�w /a-�I-/y RECEIVED <br /> 0 T � 021 <br /> SAHd10AQU5N COUNTY OCT 0 5 2 15 <br /> EWRONMENTikL <br /> H TH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: HEALTH <br /> D D /SER CES <br /> ASSIGNED TO: \ EMPLOYEE#: DATE: / CJ ( ; <br /> Date Service Completed (if already completed): SERVICE CODE: �(� )E: rf(O 0 2 <br /> Fee Amount: 13 Amount Pal /a5 "o Payment Dateb1/1S-- <br /> Payment Type Invoice# ^� Check# 15-S-[7La2— Recefved By:z <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 C <br /> �� <br />