Laserfiche WebLink
SAN JOAQUIIK'OUNTY ENVIRONMENTAL HEALTH`>10SPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> uc l_ <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> IZ L- Ohl <br /> FACILITY NAME <br /> 50 <br /> SITEADDRESS 2007& A/ 1W,QGKV1f ZE AaAD CtxyVE/VT� 95-297 <br /> Stmt Number DI Hon mName CI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number rest <br /> CITY STATE ZIP <br /> PHONE#1 E". APN# LAND USE APPLICATION# <br /> V-11) 333 — 107 Oa — /60— <br /> PHONE#2 En. BOS DISTRICT LOCATION C E <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR DON CWe-15WEV <br /> CHECK If BILLING ADDRESS <br /> PHONE# Eu' <br /> BUSINESS NAME G AS EV e-o NSuc NL 6 - o <br /> HOME or MAILING ADDRESS FAX# <br /> P o- sox I ) (a69 -Zs98 <br /> CITY L(� L OG K STATE ZIP 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared thds,is appl' tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> CouNTY Ordinance Codes,StandarA' E andF E� L laws. LL <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> /f APPLICANT is not the BILLING PARTY proof Of a horization 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: SI/RF,4CE ,i L(HS RiAGF— <br /> COMMENTS: � v <br /> , ' 6 2006 <br /> •-�UN 2 JUN 2 6 2006 <br /> �ytl!" /EN IRONMENT LTM <br /> `/ ` H�,PARZMeWENV1R0N1MENT HEALTH <br /> ACCEPTED BY: EMPLOYEE#: 3 DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: (5"> Amount Paid �, ` i (; U Payment Date <br /> Payment Type Invoice# Check# `. Received By: <br /> EHD 45-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />