Laserfiche WebLink
r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR C <br /> J[1 urs J I aUtrLA CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITEADDRESS (qZI N ESe-'AWw1 DIFLLt -r&. C.. IrJ06V 95236 <br /> Street Number Direction Stmet Name city ZIP Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ex,. APN# LAND USE APPLICATION# <br /> (2O9 ) 981— 106,176 093 - 1� -0(o P,4- /o-,?V <br /> PHONE#2 Ex. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / ' / CHECK If BILLING ADDRESS® <br /> BUSINESS NAMEFG ® PHONE# En. <br /> DIuoN /NuaON� (tot 334-brr3 <br /> HOME Or MAILING ADDRESS FAx# <br /> 1120. 13ox 2186 (tea ) 374-o77-3 <br /> CITY "')i STATE ZIP 1?57241 <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 /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL leWS. <br /> APPLICANT'S SIGNATURE: _ DATE: 4 / <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER OTHER 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, 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: r l <br /> COMMENTS: 7/1 4//d <br /> SEP 0 B 20% <br /> R 1151 it <br /> SAN JOAQUiN <br /> cOUNn <br /> ENVIRONMENTAL <br /> HF1tlTM DEPARTMEtlt <br /> ACCEPTED BY: EMPLOYEE#: ) DATE: <br /> ASSIGNED TO: EMPLOYEE#: 9 DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: S Z Z PIE:AO <br /> Fee Amount: 4-2/141 e� Amount Paid Payment Date u <br /> t <br /> Payment Type G Invoice# Check# R cei ed By: <br /> EHD 48-02-025 SR FORM(:071 d2e!Rod) <br /> REVISED 11/172003 <br />