Laserfiche WebLink
i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTFi DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY�ID# <br /> SERVICE T— REQUEST# <br /> SUU� <br /> ®VVl\tER 1®PERA(TOR �tJ1� <br /> _-- -_- _ <br /> LkA` ( � V CHECK If BILLfNG ADDRESS <br /> FACILITY NAME <br /> Aw <br /> SITE ADDRESS ,� '} <br /> v tJ <br /> Street Number Dirertiun Sfrae!N_mw W <br /> HOME or MAILING ADDRESS (If Different from Site Address) cl, zip code 111 <br />•# CITY Street Number <br /> Stree[Name <br /> STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (20 <�v�^ fl(D (Sp(P <br /> PHONE#2 "T. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR� SERVICE QU STOR <br /> REQUESTOR 'A <br /> A �7 <br /> `�L f � A- � CHECK I f BILLING ADDRESS E] <br /> BUSINESS NAME (�` / �t j�� y�i� �y C�L� /� a i _/} 4? PHUNE# B�_ ^ ` EXT. <br /> HOME or MAILING DDRE S T 61 L/T"fT i", FAX# L(1VP��I <br /> CITY 6—'K ��` CA. `�3(p STATE ZIP <br /> BILLING ACKNOV&E€3GEi'JIENT: 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 t is form. <br /> I also certify that I have prepared this apAqation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, S ATE 2Rt,.�EDE ws. <br /> APPLICANT'S SIGNATURE: /} DATE: � �l � ^ � , <br /> r <br /> PROPERTY I BUSINESS OWNER 2-- R R/MANAG ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLIWG 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 assesspt f ation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon aS it Is available and at the same time it Is <br /> my representative. •������YY]" <br /> TYPE OF SERVICE REQUESTED: {�o�' S u Gpo r <br /> COMMENTS: <br /> J�gQUIN CO <br /> �E LNFI DO kR ME <br /> T <br /> ACCEPTED BY: 6? /� EMPLOYEE#: DATE: <br /> ASSIGNED TO: �~ {� �S v' V EMPLOYEE#: DATF: Y� <br /> Date Service Completed (if already completed): SERVSCECODE: SG OLP PIE: U-2- <br /> Fee Amount: 1�� Amount Paid Payment Date <br /> Payment Type invoice# 1 Check# �� Received By, <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> S <br /> 1 <br />