Laserfiche WebLink
SAN JOAQUI. OUNTY ENVIRONMENTAL HEALTH ;PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �rS S+4:�,00 bago 66:16 <br /> OWNER i OPERATOR <br /> ku I �r e4 rn CHECK If BILLING ADDRESS <br /> FACILITY NAME v%�"� l .Xl <br /> SITE ADDRESS t(00 5 M t.�►n S{ • + I -� c <br /> r�tG n C <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I ExT• APN# LAND USE APPLICATION# <br /> (5b ) 4t-,.,co -'a3-7 1 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# ExT' <br /> Co Nn1pk an c-t. <br /> HOME or MAILING ADDRESS FAx# <br /> P'0' �Sox Sou c ) <br /> CITY r+ „ __ S 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: . / <br /> PROPERTY/BUSINESS OWNER[:] OPERATOR/MANAGER [3 OTHER AUTHORIZED AGENT Ja Cun+'-4;�1y./ <br /> If•APPLICANT 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: <br /> COMMENTS: .1 t1S�cG�It1#-i CL�-jf t r'LrG-.J S 1�-1.e--APAYIb4EPP'tf C,41 b 1C4f JLA <br /> RECEIVED <br /> MAR 14 2913 <br /> SAN JOAQUIN COUNTY <br /> FNIIIJ <br /> ACCEPTED BY: 4a EMPLOYL19WALTH DEPARTMENT DATE: <br /> ASSIGNED TO: �1a0 EMPLOYEE M DATE: 607 <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: <br /> Fee Amount: �� `' Amount Paid fP375,D v Payment Date -111q l3 <br /> Payment TypeV1' Q� Invoice# Check# �� 0� Y7 eceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />