Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR, / <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME //��,�It <br /> Sn�ADDRESS � //6 S T-9 /Cqr-r C Y C?S O <br /> s3 Z 33 Street N,,W Direction /� Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Differe tfrom Site Address) <br /> AStreet Number Street Na a <br /> CITY S /A STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION If <br /> (aog) ��2z910 2sS 9 1�4 1 ro©vLY/ i0")02' { a <br /> PHONIER Ex . SOS DISTRICT LOCATION CODE <br /> (20 ) YF2 77& 9 11 Q <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ext. <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE ZIP <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 font. <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUrN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 4/, DATE: /?-/,o// <br /> PROPERTY/BUSINESS OWNERLa OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> If APPLICANT is not the BILLING PARTY proof Of authorizaifon 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 i5 available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �'p t t` �GGC�4Pj [C-c� S 7Z.G(J PAYMENT <br /> COMMENTS: 4/U RECEIVED <br /> w�l7i�/! - 8 <br /> Q��_�'"'�_t,•- � �� �ti ! DEC 2011 <br /> r� eNJ O <br /> COUNTY <br /> ENVIRONMENTAL <br /> ; <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: p L t 06C EMPLOYEE#: O3 u DATE: <br /> ASSIGNED TO: (0 A.,u L—VS EMPLOYEE#: Z(oel-5 DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: 5'2Z PIE: 01 <br /> Fee Amount: gyp. Amount Paid a_17, Payment Date <br /> PaymentType Invoice# Check# / F^ _� I Received By <br /> EHD 49-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />