Laserfiche WebLink
F <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5' 00Lf ,8t <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS❑ <br /> ?Ocs S4tJ&Y 10 E5 rr 1 <br /> FAciury NAME sr'CNGU�N6� ) 1 Nv f 1 NC <br /> SITE ADDRESS4-77 ( �S C/4I uN t3e�La 7-(+ •�G-7�� <br /> Street Number Direction Street Name Ci 2i Code <br /> How or MAILING ADDRESS (If Different from Site Address) / 91(0319 GDpP&gvPOtr/S <br /> Street Number Street Name <br /> CITY STATE 64 ZIP q5 Z3 <br /> LINI)Eij <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> PHONE <br /> EXT. BO$DISTRICT LOGA710N CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR r CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME t PHONE# EXT. <br /> k d��f� MUtip -6613 <br /> HOME or MAILING ADDRESS FAX# <br /> v �Jox 2430 CUM) 334-0-7 Z1 <br /> GrrY LpI STATE C- ZIP RSz4.( <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> I F' acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> i or activity will be billed to me or my business as identified on this form. <br /> I"also certify that) have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> r:'.: COLFNTY Ordinance Codes,Standards,STATE and F KAL laws. <br /> APPLICANT'S SIGNATURE:SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 13OPERATOR I MANAGER ❑ OTHER At1TIIORiZED AGENT❑ <br /> k , If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> 4. <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 environmentaVsite 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 /> 11EE -."provided to me or my representative. [ n <br /> F TYPE OF SERVICE REQUESTED: t L J U I j,��il L 'vt En17- <br /> COMMENTS: �I �` <br /> 1 SEP 8 206 <br /> 'q[ 13 R rG O <br /> [ ��`�/ �NtOAQU1t11 COu�TM <br /> H�L77I')'EPA <br /> ��,� <br /> SME <br /> ACCEPTED BY: 0t✓t UE I t?A EMPLOYEE#: o 3 L j DATE: C [F <br /> D/- <br /> ASSEGNED 70: J'T( EMPLOYEE#: 7 3 7 9 DATE: Z Q b <br /> Date Service Completed (If already completed): SERVICE CODE: Z PIE: �� p <br /> Fee Amount: l U - Amount Paid Q 1O, Payment Date t- <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> i REVISED 1111712003 <br /> } <br />