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SAN JOAQUIN COUNTY ENVIRONMENTAL IIEALTII DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �2oot�217 J <br /> OWNER/OPERATOR <br /> CHECK HBILLING ADORES <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Rik oA✓e7�h �%�/S <br /> Stree[Number Diredon sleet Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) -- C Xi cede <br /> Sleet Number Street Name <br /> CITY <br /> STATE ZIP <br /> PHONE#t ' Ez. APN 0 LAND USE APPDCAnoN# <br /> PHO1IE02 Esr. 4-" f> /1K <br /> ( ) 5 DISTRICT LocanoN CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR / /v' <br /> CHECK H BILLING ADDRES <br /> BUSINESS NAME �/ } <br /> PHONE Exr. <br /> HOME or MAILING ADDRESS FAX# <br /> ( '<p► 33�f- 67�� <br /> CITY j STATE <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized gent 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 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;FEDRAL laws. <br /> APPLICANT'S SIGNATURE: DATE: s Y "P S-- <br /> PROPERTY IBUSINES$ON'NEa❑ OP TOR/ AGER [IOTNER AUrfIOR1ZED AGFdi]',CJ 5' <br /> /jAPPucANT is not the B/cumC PAR7T proof of aut/eorizadan to sign fs required Titre <br /> Z__AUTHerty ORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the proplocated at the <br /> 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: 51 -e —ti q Y <br /> COMMENTS( /p//O IDS , <br /> q 42005 <br /> FIV QU//y O <br /> 7 oZ HF�T ROAt OUN <br /> yD 4 NT <br /> ACCEPTED BY EMPLOYEE#: <br /> ASSIGNED TO: s - <br /> EMPLOYEE#: ,L DATE: <br /> Date Service Completed (H already completed): SERVICE <br /> PIE: 7� <br /> Fee Amount: C Amount Paid - - Payment Date <br /> r <br /> Payment Type <br /> Invoice# "Check#�" Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2DO3 SR FORM(Golden Rod) <br />