Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> /�cr is FA00 y5 S12-Cb7F"�3-(,) <br /> e5iOWNER OPERAT R <br /> Q—\� ^�\ Q(— CHECK if BILLING ADDRES <br /> FACILITY NAME / 0. llh <br /> SITE ADDRES �O � ^ ^ � \ ^^ ` - <br /> Q St e[Number Direction 1"\v�Y5 r¢et m'eT( '�� .Jc 'CwY\ ZI Code <br /> HOME or MAILING ADDRESS (If Differeq from Site Address) <br /> r <br /> % Street Number tl SlreetN3me <br /> CINr� r,� STATE Zl <br /> , `( <br /> PPHHONNEE A \-\r-- <br /> . _130 <br /> � �0 v E%r. APN# LAND USE APPLICATION# ", 6 <br /> a, ` O Q <br /> PHONE#2 EYr. BOS DISTRICT LOCATION CODE <br /> Q ) 0 —� ,� J <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADORE <br /> BUSINESS NAM �� \`^ n PHONE# �E <br /> V� 46 <br /> Q <br /> HOME or MAILING ADDRES // r� FAX# <br /> CJ' C G ' O�\�'\ A- ( ) <br /> CITY G. $ TE 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 /> 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 ZlIaRAL I <br /> t Za <br /> APPLICANT'S SIGNATURE: DATE: G <br /> PROPERTY I BUSINESS OWNER OPERATOR I 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/siteassessme/r�t information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS prime Or <br /> my representative. �_�'�7•.MY' <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: O2 4?0 <br /> f__ 18 <br /> ��FNT <br /> ACCEPTED BY: EMPLOYEE M DATE: 1 <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1-41 <br /> Date Service Completed (if already completed): SERVICE CODE: ��l PIE: <br /> Fee Amount: Amount Paid /,S,2 oD Payment Date Z <br /> Payment Type _ Invoice# Ch # 22 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />