Laserfiche WebLink
SAN JoAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FAC1UTY!D# SERVICE REQUEST# <br /> OWNER I OPERAYOR \tr~rIFrEL P4tl 1.L.l P S CHECK if BILLING ADDREESSW <br />} <br /> I FAaLrTY NAME p ttl L.L.I p S: P P-04 E R'ry <br /> SITE ADDRESS 3 9 D W• ti� Act 1 2� (rCC (Cr+�P 9�Y�-O <br /> Street Numb Diry Ci i C <br /> gg <br /> HOME or MAILING ADDRESS (if Different from Site Address) X21 p W O OT> OX) <br /> Street Number Street Name <br /> CITY Lp D 1 STATE C-k ZIP q S 2-4 7 <br /> k Exr• APN# LANo Use APPLICATION# <br /> I PHONE#1 <br /> cdwlk�©9-v-,2."+ pp,- l hoot sS <br /> PmonE#2 ExT- BOS DiSMOT LDGATEQiV OpE <br /> CONTRACTOR/ SERVICE REQUESTOR I <br /> REQUESTORCHECK If BILLING ADDRESS <br /> PHONE# ExT. <br /> BusiNE=ss NAME 7^I 3(pq-o�j• S <br />{ HOME orMAELINGADDRESS FAX# <br /> - r-4 0� �`'• (yob) <br />{ <br /> CITY t�b� STATE: C ZEP <br /> BILLING ACKNO LEDGPMENT: 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 1 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 FEDERAL laws. i <br /> � <br /> APPLICANT'S SIGNATURE: nATF: <br /> I <br /> PROPERTY/BUSINESS OWNER PERATOR I MANAGER © OTH AoTHORaED AGENT❑ <br /> If APPLICANT is not theBiLLINGPAR proof of authorization to sign is requiredIs Title <br /> AUTHORIZATION TO RELEASE INEQRM& 9N- When applicable,I, the owner or operatdr of the property located at the <br /> above site address, hereby authorize the release of any.and all results, geotechnical data andlo environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT.as snore as it is avI�ilable and at the same time it is <br /> provided to me or my representative. I <br /> I <br /> TYPE OF SERVICE REQUESTED: 1L&v t E w SD I L SU E T{�cFv1�iTy S"►vo PAYM <br /> cDEitINEcNTS: <br /> SA NNp ROx '\iS�nEN <br /> q„" <br /> AccEPTED BY: EMPLOYEE 2f ©ATE: ! 2- r 4 b-6 <br /> Dirrve( E <br /> ASSIGNED TO: EMPLOYEE BATE: l Z 14. <br /> L� f g <br /> Date Service Completed (if already completed): SWICECODE; SZ Z PFE: 2�0 <br /> Fee Amount: Amount Paid Z4�{4 Q Payment Date �y <br /> Payment Type L� invoice# Check# f Received By: <br /> SR FORM(Golden Rod) <br /> EHO 48-02-025 <br /> REVISED 19/17/2003 <br />