Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# /JS�ERVICE REQUEST# <br /> `;(2t'0 <br /> OWNER I OPE <br /> RAT R <br /> �� #S C � % e�+t-J� CHECK If BILLING ADO <br /> rr"�� ,/ �/ /�- <br /> FACILITY NAME <br /> SITEAADDREsss eft e1g1 V4?4i d Al lo✓ /C.�3 7` <br /> Street Number D.,e tion S eet Name <br /> HOME or MAILING ADDRESSGff Different from Site Address) /IYV <br /> ro '.0V � / Street Number St.t Name C- T <br /> Cm /-A J�' 2 <br /> EE ZIP <br /> Y y NO <br /> PHONE 01 /-"! K�C�j- APN X LAND USE APPLICATION# <br /> PHOMER EM. BOS DISTRICT LOCATION CODE <br /> IG ) :2 PP" p � c <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Su � / CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Es.. <br /> HOME or MAILING ADDRESS FAX# <br /> 1 ) <br /> CITY STATE ZIP <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 <br /> or activity will be billed to me or my business as identified on this forth. <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, TATE and FED <br /> /E <br /> /Rp�AL laws. <br /> APPLICANT'S SIGNATURE: A C' DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> 1fA,PPLLCANT is not the B/LUNG PARTY.proof of authorization to sign is required rule <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator 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 HEALTH 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: St- <br /> COMMENTS: It Il3 µJ ECEIVF <br /> OCT 28 2013 <br /> SAN JOAQUIN COUI ON <br /> ENVIROMENTA <br /> HEALTH DEPART <br /> ACCEPTED BY: rlEMPLOYEE#: �1 i 7o DATE: <br /> ASSIGNED TO: /re G� EMPLOYEE III: 41-pf/.� DATE: <br /> Date Service Completed (ff already computed): SERVICE CODE: -2.>I S P/E: Z O 3 <br /> Fee Amount: Z Amount Paid �J f Payment Date /D Zy /3 <br /> Payment Type y ' Invoice 8 Check# 9 02 Received By: <br /> EHD 49-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />