Laserfiche WebLink
/.7/`7 4 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT � l �� �I'7`7 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 OPERATOR�r <br /> zQ CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS 13 E5 <br /> Street Number Direction WStreet Name I—vcity rZl Code l <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street NumberF Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR TQ W} rn CHECK if BILLING ADDRESS <br /> la <br /> BUSINESS NAME /� 5 l- 0 n©1 I / ,� (7 PH�# ��Li -_� 1 v 0T <br /> HOME or MAILING ADDRESS j 5 5 }('C� Yj i�(/, `�NO A A ,5� f 1 FAX# <br /> CITY 1 OC I STATE ZIP e!� <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 1 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: Q& - 01 - 1 -7 <br /> PROPERTY I BUSINESS OWNE� OPERATOR/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 environmentallsite assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same It is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: IJ�1 --}-� on ElyED <br /> COMMENTS: JUN 1 2017 <br /> SAN JOAQUIN <br /> COUNTY <br /> FIEALTy p ARTMevr <br /> ACCEPTED BY: CLOAEMPLOYEE M DATE: '- , <br /> ASSIGNED TO. ! EMPLOYEE#: DATE: r(/�+1 <br /> Date Service Completed (if already completed): SERVICE CODE: P1E: � <br /> Fee Amount: Amount Paid ¢ `?�l.�. �. Payment Date 4714 /1 <br /> Payment Type V •S a Invoice# Check# Received By. <br /> CPO 4 75*5J D <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />