Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRPNNIFNTAL HEALTH DEPARTMENT <br /> �., SERVICE REQUEST <br /> Type of Business or Property FACILITY ID 111 SERVICE REQUEST# <br /> acid" zox/ aeogq'7-75 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FAcIL"NAME <br /> aer✓ii,�' r J <br /> SREADDRESS /30Q ^/ t�Y/{W �i4ELd �Q/' dJ <br /> Street NumOer DirectioT Street Na. Cit ada <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number tree Name <br /> CITY STATE Zip <br /> PHDNE#I ExT. APNM SE APPLICATION# LJLkAND <br /> D6--AI.74ls) <br /> PHONE g2 Exr. STRICT LOCATN)N CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORR <br /> CHECK if BILLING ADDRE5SL1 <br /> BUSINESS NAME \/ T ! „L PHONE II Exr' <br /> Sa«� 931- obs/ <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE zip <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAi-HEALTI I 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 1 have prepared this application and that the work to be performed wec ttN>tc�md� th all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. \\�J� I�JIB' U <br /> APPLICANT'S SIGNATURE:�r � `� �• DATE: <br /> PROPERTY/BUSINESS OWNER. • OPERATOR/MANAGER ❑ OTHER AUTUOR2ED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof dfaa/hdrizalron to sign is required Tine <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the properly located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> infOrmalion to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAI.rli DEPARTMENTas soon as it is available and at the same time it is <br /> provided to tie or my representative. <br /> TYPE OF SERVICE REQUESTED: , Q2 T <br /> COMMENTS: (L'112_1e; i.,�, rod D <br /> 7.+� NOV 10 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTME <br /> ACCEPTED B EMPLOYEE#: DATE: a <br /> ASSIGNED TO: T �/� 1/ EMPLOYEE#: 7 q % DATE: V <br /> Date Service Completed (if already completed): SERVICE CODE: / PIE: <br /> Fee Amount: Amount Paid g b Ov I Payment Date \\ b 0S <br /> Payment Type L/ Invoice# Check# L. 3 Received By: (1 <br /> EMD 4"2.025 SR FORM Mf lden RMI <br />