Laserfiche WebLink
SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID It SERVICE REQUEST# <br /> IL <br /> OWNER/OPERATOR i <br /> III\t ( ^` p Y) nI _(J`(� CHECK If BILLING ADDRESS <br /> FACIUTY NAME ` T ` <br /> r S0. �Jc:x k ; ',' h q 1 <br /> SITE ADDRESS 1 (0J N Ulf 'SC, VJ Lift Sko C� �dh C f4 <br /> Street Number pirection Street Name) city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 1 I I l (so 'I l 'I a Q <br /> Street Number Street Name <br /> -1 <br /> CITY STATE ZIP <br /> S o� o e �4 C15 20 S <br /> PHONE#1 EKT. APN# LAND USE APPLICATION# <br /> ( 510 a60 <br /> PHONE#2 EXT. BOB DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 1 u�,� e,_,.II-, Z� �� �e CHECK If BILLING ADDRE55O <br /> BUSINESS NAME " ` T'�ChL�LYf PHONE# EKT <br /> (--S 0\" ' U Ck e� v.�( . - D a o <br /> HOME or MAILING ADDRESS1 MI A I II FAX# <br /> rT&t AJ sa Y1 W Q ( ) <br /> CITY C K STATE C ZIP R5 /-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 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 that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATEand FEDERAL laws. <br /> APPLICANT'S SIGNATURE: VI'IK-�a /IIIrVIJ0tCA DATE: Z3 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required 7YNe <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 Iit.frovided to me or <br /> my representative. YME T1 <br /> TYPE OFSERVICE REQUESTED: C, - - �� , _ Y RECEIVED <br /> COMMENTS: MAY 2 3 20 <br /> SAN JOAQUIN COUNTY, <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENTi <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: I lJ� EMPLOYEE M DATE: <br /> Date Service Completed (if eadycompleted): SERVICE CODE: <br /> Fee Amount: `}� I 2.Jr� Amount Paid 5"e� _ Payment Date S/A 3 1 Q <br /> Payment Type Cn S Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />