Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FAcll ITV In SERVICE REQUEST# <br /> 1%)OY Ov )1\ l Z0 �• <br /> OWNER/OPERATOR f n <br /> `nC CHECK If BILLING ADDRESS <br /> FACILITY NAME —row Y) 11 l�lQ\)WS <br /> SITE ADDRESS7)4 1wyt)1 I�V.i�r�CLX C� �I%G3� <br /> lVl Street Number Direction Cl Street Name CI Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address)1 ♦ � <br /> 1 (] Llv• Street Number Street Name <br /> CITY `,SDI STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# i <br /> (2171) -42-4 -5985 0IgDC°fUC67D <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( l - OD 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR n <br /> �1�vavv\ C �` CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT, <br /> I Owyl COLAA L1QljdvS (2"4 ,6 <br /> L4— U CU <br /> HOME Or MAILING ADDRESSV—+ LPeu&r4 f✓� (A%# ) <br /> CITY -j rCk STATE C* ZIP (tCJ7 oi_j <br /> BILLING ACKNO LEDGEMENT: I, the undersigned property or business owner, operator or authorized agent off 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 the hq rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT nd DERA <br /> APPLICANT'S SIGNATURE: DATE: IC2 �g <br /> PROPERTY/BUSINESS OWNERS OPERATOR/MANAGER El OTHER AUTHORIZED AGENT LJ <br /> If APPLICANT 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 i�g above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessme rl% <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 Soon a5 It Is available and at the Same time It is proV NT <br /> my representative. <br /> Ju <br /> TYPE OF SERVICE REQUESTED: I �rL — AGOG C•ov15\An� I'I ' pD <br /> COMMENTS: ✓0.QU/NO O <br /> �O�1S�1� Hw�oFa ENr� n <br /> AR7-4Z r <br /> ACCEPTEDBY: EMPLOYEE DATE: <br /> ASSIGNED TO: 1r lml EMPLOYEE DATE: <br /> Date Service Completed (I already completed): SERVICE CODE: Db 1 P1 E: �,O <br /> Fee Amount: -0? 152_- Amount Pa' �Sa• d� Payment Date �S <br /> Payment Type Invoice# CI dck# 7V�S-S3 eceiv'ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 C w w <br /> v�~vV� <br />