Laserfiche WebLink
i <br /> 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 /> I <br /> FACILITY NAME-7_EkQeA (Qq-7 r <br /> SITE 3gp_ ss ►� hf1��Y., <br /> �( Street Number Dlrectlon Street Name Cit ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name l <br /> CITY STATE ZIP <br /> l <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR_ <br /> CHECK if BILLING ADDRESS <br /> '6J li G i <br /> BUSINESS NAME p PHONE# En. <br /> �C. Se�rv�ce.S 6v% `l�Ey-�Z3b <br /> HOME or <br /> MAILING ADDRESS{ FAx# <br /> (SS-.j ) }Lit{-1-7,W <br /> CITYY`�'S STATE ZIP g37Z 7 <br /> BILLING ACI(NOWLEDGFMENT: I, the undersigned propet•ty or business owner, o`pePratot• or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEAL't'tt 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: DATr: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHFR AUTHORIZED AGENT <br /> Ifffl'PLICANT is nol the BILLING PARTY' proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or opet•ator 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 HEALTit 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: V V -JA Y M C-)) D <br /> COMMENTS: -Oe/fin -q m <br /> rV <br /> i,. 02 — <br /> Sq��o F5 rV C <br /> ENVIgQ1Il.> fJp�p in 0 <br /> H ?'HROI.M� 7 Ueityi til =_� <br /> ACCEPTED BY: EMPLOYEE M DATE: V <br /> ASSIGNED TO: LIY I� EMPLOYEE M f(�) DATE: ''l, _ <br /> Y LL!! <br /> Date Service Completed (If already completed): SERVICE CODE: J Q P i E: Og <br /> Fee Amount: ` Amount Paid . T-` C _fir. Payment Date j0 2-1 <br /> Payment Type /I k1 Invoice# Check# �o Received By: <br /> EHD 48-02-025 L/l C.% y .9 r f 1� I t , SR FORM(Golden Rod) <br /> REVISED 1 111 712 003 <br />