Laserfiche WebLink
SAN JOAQUIN —,)uNTY ENVIRONMENTAL HEALTH nEPARTMENT <br /> ... SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> QHS/D�n/T/R GA 2(e WI -iV,q AS�Zcz � � U <br /> OWNER/OPERATOR <br /> I�VS. ,Cv�L <br /> FAcaIrYNAME J - / �RDLIT CHECK If BILLING ADDRESS <br /> /v <br /> SITEADDREssF2�.v�N C/fi�iP RO n'/AA./--c-A %s 34" <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PSE#t EXT APN# LAND USE APPLICATION# <br /> I ) 9WZ- foq_-33 177- . a2 EA - G —/O 00 <br /> PHONE#2 EM. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �I ) _ <br /> J o� /�/ /�! ,I /� CHECK if BILLING ADDRESS <br /> BUSINESS NAME ,� G�r-T J 'v PHONE# EXT. <br /> FsNF_ COAISu,(-7-/A/C X60-463 <br /> HOME or MAILING ADDRESS FAX / / Z5 <br /> SOX ( ) 8� -7g <br /> CITY ', `/ O STATE e" /1 ZIP S J c, <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 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 'on and that work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S ' and FERE s. <br /> APPLICANT'S SIGNATURE: (lvh4DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAZAGER ❑ OWMR AUTRORIZED 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 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: Sct/I A CE A AI.D'fgW6SKrP/�h C'c�N%A,r/N�Tion//ZEPozT EA/D <br /> trr/c� w � utN co <br /> UNN <br /> �j�iA.a�rsee?� S EN�RO EPppNTTM� <br /> ACCEPTED BY: LtE.V I l—A EMPLOYEE#: p 3 z/ ATE 22(4 I DS <br /> ASSIGNED TO: S C-OT/'[) EMPLOYEE#: S L(r! DATE: Z Ct(0 <br /> Date Service Completed (ff already completed): SERVICE CODE: 3/S PIE: <br /> 026.03 <br /> Fee Amount: )F(� o Amount Paid D 60 Payment Date <br /> Ym Type Payment T Invoice# Check# A7 � Received By: <br /> �' <br /> EHD 48-02-025 SR FORM(Colden Rod) <br /> REVISED 11/17/2003 <br />