Laserfiche WebLink
SAN JOAQUIN UNTY ENVIRONMENTAL HEALTRA�PARTMENT <br /> k <br /> SERVICE REQUEST �- <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> RC-.<t E V-464Al silo v q Z (D z0 <br /> OWNER I OPERATOR <br /> 0w f ��Z1 7-1 � L CHECK If BILLING ADDRESS <br /> FACILITY NAME �V <br /> SITE ADDRESS j>/'ErR MIDAE�AJ �S-2 36 <br /> o Street Number I Direction Street Name citv Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ex-r. APN# LAND USE APPLICATION# <br /> { ) 46 p s- 'R-;10 - A-65--/z7 s <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> DD �/ CHECK if BILLING ADDRESS <br /> 4 BUSINESS NAME fI CSw ,fF C��N�GCGT//VC PHONE# Z� r D3 ExT. <br /> HOME or MAILING ADDRESS 'V FAX# j5 <br /> CITY �`/ Lac/� STATE /r ZIP <br /> I BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> i 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 /> I also certify that I have prepared this appli ion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST and FEDE5APaws. <br /> APPLICANT'S SIGNATURE- DATE: - ZG <br /> M <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/ ANAGER © OT AUTHORIZED AGENTAN <br /> IfAPPLICANT iS not the BILLING PARTY,proof of author' ation to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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: 2 ffF C �c jLl f�SU RF/.� f6Ni A�'t rN A Tt o N �PoR r- 1//�t� <br /> COMMENTS: Z ��j I��, JI PAYM <br /> o'25-7 t Rt�CEIVED <br /> .F �s�o-rzc� ��-a ' JAN 2 <br /> �(oUnii�J� �� <br /> sAN soAQNnn��A� ! <br /> ACCEPTED BY: [^(� I EMPLOYEE#: 3 Z r HEALTH tX- ATE: f -2 <br /> ASSIGNED TO: FS"Tr EMPLOYEE#: `j tE Y DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3!5 PIE: 6 Q3 <br /> Fee Amount: (e['.00 Amount Pald Payment Date <br /> Payment Type Invoice# Received By: <br /> -02-025 <br /> EHD 48 <br /> SR: ORM.( tldenRod} <br /> REVISED 11/17/2003 <br />