Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑/ <br /> FACILITY NAME <br /> Allcl 5c- <br /> SITE ADDRESS �r U tyllig-V A �,1�'1401 kAt STU-4fK)yl `/ ✓` <br /> Street Number Direction I Street Name ✓ IS city ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (t ICEI <br /> Lq <br /> PHONE#2 EXT. BOS DISTRICT —] LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> k! l CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1 PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY 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 spec ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as idents' don this form. <br /> also certify that I have pr&C", ' <br /> tion an that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, nd FE RAL laws.�-APPLICANT'S SIGNATUDATE:PROPERTY/BUSINESS OWNE /MANAGER ❑ OTHER AUTHORIZED AGENTIfAPPLICANPARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELTION: 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 time It IS provided t0 me Or <br /> my representative. 1L PAYMENT <br /> TYPE OF SERVICE REQUESTED: i,-0 i���-I[ Tn LtkA.) RECEIVED <br /> COMMENTS: <br /> MAY 19 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �"IWf �l�t EMPLOYEE#: DATE: 5- '1—17 <br /> ASSIGNED TO: I-l�>, h EMPLOYEE#: DATE: '16o-,> <br /> �JqA 7 <br /> Date Service Completed (if already completed): SERVICE CODE: P//'E: i r Q. <br /> Fee Amount: , (3 0 Amount Paid Payment Date f r q <br /> 1 <br /> Payment Type C�L Invoice# Check# Received By:, <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />