Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ' SERVICE REQUEST# <br /> OWNER 1 OPERATOR _i <br /> Jfv DOwtCB0 CHECK If BILLING ADDRESSO <br /> FAcuff NAME �`�C��/ <br /> Z S <br /> srre ADDRESS -T <br /> 0 P'1413 <br /> - .aj- j — <br /> Slroet Number Direction Street Name citx ZIP Code <br /> ]NOME or MAILING ADDRESS (If Different from Site Address) J ! C ox, <br /> Street Number Street Name <br /> CnsY (/rN STATE 04- ZIP <br /> t PHoxE#t <br /> EXT. APN OLAND USE APPLICATION ax <br /> - f . I !g� - Z3v -13 • <br /> PHm 92 ExT• SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Ire IV,V'` CHECK H BILLING ADDRESS <br /> BusixESs NAME f� � J� t PHONE# EXT. <br /> P1 WV 46 <br /> plaw GG �3 <br /> HOME or MAIUNG ADDRESS Fnx# <br /> Z p u I a ) 53W o•7 Z 3 <br /> CITY STATE . A ZIP G���Z <br /> L t N E1V ci`t J <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 form. <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 /> COUhITY Ordinance Codes,Standards, STATE and FEDERAL laws. - <br /> •APPLICANT'S SIGNATURE: DATE: �7 <br /> PROPERTY BUSINESS OWNER❑ OPERATOR MANAGER ❑ OTdER 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite 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: --U <br /> CoaNMErtrS: (,/"/�-7 RECEIVED <br /> JUN 14 2007 <br /> SAN JOAQUIN COUNTY <br /> is <br /> ENVIRONMENTAL <br /> ACCEPTED BY: L-.t GSC�� EMPLOYEE#: D E: �V C. <br /> ASSIGNED TO: �� � EMPLOYEE#; DATE: f O <br /> � l <br /> Date Service Completed (if already completed): SERVICECODE: 3jS P112;- 03 <br /> Fee Amount: 4 ,150, Amount Paid Ila. 0 Payment Date (0 1 o <br /> Payment Type j/1 S Invoice# Check# S70 �(tfa Sb Received By: <br /> EHD 48-02-025 + 1 I©(- 6117s <br /> SR <br /> REVISED 11/17/2003 1 ORM(Golden Rod) <br />