Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR n <br /> �W _ 1' . ..,r1_\1f�'II'��.t,^ ��'j� CHECK If BILLING ADDRESS� <br /> FACILITY NAME �YVti �,(,�Jwl,lQ� (—L C ✓5Y 1A I k v �1 <br /> SITE ADDRESS I(�Sa / 1 1v I��o ' I A 1�.t'I' I1 (— Ln!'-� qG3 3(,., <br /> She ANumber Dlrectlon I— l "� SVtrvee`t/Na'rhe 'V\ CICS..-d ZI Catla`I� <br /> HOME Or MAILING ADDRESS If Diff rent from Site Address) <br /> Stroet Number NeetmE <br /> CITY STATE C ZIP _�} <br /> l;-3 3(o <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (t) 33a- Slop aal�bb�ID <br /> PHONE#2EXT. BOS DISTRICT LOCATION C DE <br /> (�09) 4'6( -S S t`� 6- � D <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQDESTOR �W� , A I A A�ry`,^� CHECK IfILL <br /> XMGADDRES <br /> B <br /> BUSINESSNAME Vv 1V\01 \ 1` r. (^ PHO E# EXT. <br /> 5,vn LLC b <br /> HOME or MAILING ADDRESS FAX# <br /> u( ( ) a3a- 00 <br /> 5 <br /> CIN fS�..�A -a STATE ZIP I JS <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 /> also certify that I have prepared this application and that the work t be performed will be done in accordance with all SAN JOAQUIN <br /> ED <br /> CO ERAL NTY Ordinance Codes, Standards,S TE and F ')WS. <br /> PPPLICANT'SSIGNATUR�EI: DATE: /a- -301-7n� <br /> PERTYI BUSINESS OWNER W OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessnfor�matiionn <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the same time It IS p <br /> my representative. __•"', <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: O� <br /> O� SAN JOAQUIN COU <br /> ENVIRONMEN N <br /> C. Q Lei C5 Y— D ��c i HEALTH DEPARTTA ry <br /> ACCEPTED BY: 'I-)Je, ,t U EMPLOYEE#: DATE: <br /> �, <br /> ASSIGNED TO: �(1 I EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: d � PIE: <br /> Fee Amount: r/ Amount Paid Payment Date / -7 <br /> Payment Type �7 i Invoice# Check# Received By: <br /> Y yp <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />