Laserfiche WebLink
SANJOAQUINCOUNTY ENVIRONMENTALHEAL1H.LEPAKI vttxN1 <br /> .r <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST# <br /> dJso �- 15 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME n C 1 <br /> SITE ADDRESS 1`4U-1 E Vnc,�� V-& CG m96 Gr�j Z <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number C211tel <br /> CITY STATE Zor <br /> PH0NE#1 E�T. APN# ELANDE APPLICATION# Q/� /r� t�Lqp - ( � �� A- tion 1PHONE#2 EXT. TRICT / LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR� ` \e <br /> CHECK IfBILLING ADORE55 <br /> BUSINESS NAME PNQNE# EXT. <br /> HOME or MAILING� gESS FAX# <br /> CITY STATECPT ZIP - <br /> tj- <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 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 laws. <br /> APPLICANT'S SIGNATURE: vt A km. ` ` DATE: 5 �k')De-XLA PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT C <br /> IfAPPLICANT is not the BILLING PAR proof ofauthorization 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 enviroDmental/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: <br /> COMMENTS: <br /> 4 2001 <br /> RECE� <br /> � c MAY 2 <br /> U�.i <br /> GO13011 <br /> r SAtjOA <br /> ENDEPAST'Ai- <br /> TN <br /> ACCEPTED BY: ,Gp,O NM�C11M 1,jC EMPLOYEE M J y� DATE: <br /> ASSIGNED TO: WkA .,I� EMPLOYEE#: tr.? t&G DATE: <br /> Date Service Completed (if already complete ' G {+- - SERVICE CODE: Cf')/ PIE: 6 <br /> Fee Amount: 1 O t!� Amount Paid IG��, O Payment Date 'E12-V07 <br /> Payment Type ` Invoice# Check# -7y.�— Received By:- <br /> EHD 48-02-025 'p�ITE SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />