Laserfiche WebLink
w <br /> R4�NJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 6-7 �) 5 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE AD <br /> DRESS - O114)15 <br /> 85-14, f et <br /> Name city Zin Code <br /> HOME or MAILING ADDRESS (if Different from Site Address/ 710 <br /> Street Number treet Name N <br /> CITY �j�7 l� �.���� STATE ZIP <br /> PHONE#1 � EXT.� APN#0 LAND USE APPLICATION# <br /> F <br /> PHONE#2 EST. BO$DISTRICT - LOCATION CODE <br /> w CONTRACTOR 1 SERVICE REQUESTOR <br />� REQUESTOR <br /> !2- CHECK if BILLING ADDRESS <br /> BUSINESS NAME � � (/ PHO <br /> r <br /> HOME or MAt NG D RESS FAx# <br /> CITY 1 ,�rfi a STATE / ZIP <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 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, Kisnot <br /> ?the <br /> RBILLINGPARTY, <br /> ERAL laws. <br /> APPLICANT'S SIGNATDATE: ,3��1 ! 7 <br /> PROPERTY/BUSINESS OWNENAGER © OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANproof of authorizationto 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 environmental/site assessment information <br /> to the SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon as it Is available and at the Same time It ES �y,�ed to me or <br /> my representative. �+ <br /> TYPE OF SERVICE REQUESTED: EI <br /> COMMENTS: AMR 16 7 <br /> pn n s'4N�oItN V,a 2D17 <br /> Q DEcoumry <br /> pq�Mehr. <br /> ACCEPTED BY: EMPLOYEE#: DATE: 7 _ . 1-7 <br /> ASSIGNED TO: G EMPLOYEE#: DATE: 5 1 L117_ )"1 <br /> Date Service Completed (• Iready completed): SERVICE CODE: U P1 E: D <br /> Fee Amount: 1 pU Amount Paid 1 J��Ot� Payment Date c l�O �'7 <br /> Payment Type ( Invoice# Check# b�0 Received By: CJ <br /> EHD 48-02-025 5R FORM(Golden Rod) <br /> 07/97/08 <br />