Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# /SERVICE REQ(U�EST# <br /> Cl I- ✓P" ff 77/k7;�-) <br /> OWNER I OPERATOR ,r <br /> Ec.FO /Y/ CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> e1n,eFL,ere <br /> SITE ADDRESS 3S// C/[/�QQ�iE� �7D, $TOG�Ory 9S�ps <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 130 917 ""-AD <br /> Street Number Street Name <br /> CITY STATE eA ZIP <br /> PHONE#t EXT' APN# LAND USE APPLICATION# <br /> '� ) Go/- 7a9d V,4- 17e0611 <br /> PHONE#2 EXT. BOB DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ <br /> /1 O a / �� CHECK If BILLING ADDRESS <br /> BUSINESS NAME /V (//'r L PHONE# EXT. <br /> ell W F 4 69AIe- A2 -/G <br /> HOME Or MAILING ADDRESS FAX# <br /> Po bd -as9 <br /> CITY �/i LOG/ STATE e,4 ZIP 5 jiq <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,S E and FE RAL laws. <br /> APPLICANT'S SIGNATURE: DATES: 7- 7Y- 17 <br /> PROPERTY/BUSINESS OWNER ElOPERATO /MANAGER ❑ OTHER AUTHORIZED AGENT BO/ <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/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 to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: /V/ 0401AIr <br /> A01L. L(� ,9 p c <br /> COMMENTS: _ OJ / rP/� 'Nfir�!7 C"CC�V�� <br /> J <br /> / TT S� U( 75 Z01) <br /> 7 /d.� (QCT HN�Rp/U COU <br /> M <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: _ J EMPLOYEE#: DATE: t IF <br /> l <br /> Date Service Completed (if already completed): SERVICE CODE: L PIE: -Z <br /> Fee Amount: - Amount Paid�� �,� Payment Date 7/ 7 <br /> Payment Type /X k, Invoice# Check# 3c/�:-d. Received By: l <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />