Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> /CSS/PENT/AL euiTNR,4L yz, D6-7 `6c 2� <br /> OWNER/OPERATOR ca M4-\/L1 <br /> . Y <br /> ,//Afl-e, CHECK If BILLING ADDRESS <br /> FACILITY NAME t'1 <br /> SITE ADDRESS3�Q�D 5TAC 'w/ 9r;%; <br /> Street Number Direction Street Name Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> SnE Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> �a ) G29- 3 - �¢o-osIfP,4 Sao <br /> PHONE#2 EXT. BOS DISTRICT / LOCATIOI{CODE <br /> C)C <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> D0,1 I / •,/ � CHECK If BILLING ADDRESS <br /> BUSINESS NAME r4 ,V G- PHONE# EXT. <br /> s o n� u to <br /> HOME Or MAILING ADDRESS FAX# <br /> 3Z P ) GGB•Zf <br /> CITY 11u R LD Cly STATE CQ ZIP / <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 /> also certify that I have prepared this Eilication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, T E and FED L laws. <br /> APPLICANT'S SIGNATURE: DATE:t 7 <br /> PROPERTY/BUSINESS OWNER❑ OPERAT- /MANAGER ❑ OTHER AUTHORIZED AGENT 61 <br /> If APPLICANT IS not the BILLING PARTY, proof Of aut orization to sign is required Tille <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time it'w2vided to me or <br /> my representative. //'_9) ' <br /> TYPE OF SERVICE REQUESTED: W1 _t 0 Etv y <br /> COMMENTS: 3/r3/7TOf�j AhjE� O�Y�� (fpp,m�N�'g3 qR0 <br /> G �'�'✓o ?418 <br /> H 7'H�MBCOUN <br /> OFagR�T-1N TY <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Com leted (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: •p Amount Paid 3 jjD Paymen ate 7 <br /> Payment Type Invoice# Check# 3 77 Received By:ayl <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />