Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ESERvIc <br /> E REQUEST#fGlr 0L7I)kAL AF�ty; 251-050-03 32 �Q l <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> SAM AND MA�1� T�Ss!� <br /> FACILITY NAME <br /> SITE ADDRESS Z73�y So LAM Rona —(RAc( g' <br /> Street Number Direction Streel Name CI ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 5n tel 1-115 12r) RoAo <br /> CH,Sc%_ 'TUSo <br /> 2 4-19 -o. 7'" � ;K- .��. .o t Street Number Street Name <br /> CITY -rnAc( STATE �. ZIP 95�7_, <br /> PHONE#1 Exr• APN# LAND USEAP ION# <br /> (za9) 839 -5761 N/A P (� <br /> PHONIER EM Wp, 505 DISTRICT LOCATION CODE <br /> (zr)9) 535- 5916 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR WAL-Tr�tZ 1✓ CLS SUIS CHECK If BILLING ADDRESS® <br /> ' <br /> BUSINESS INANE GG I V I L EN(�l t.;.E,C R, PHONE#c�fj 368— 4 t <br /> HOME or MAILING ADDRESS FAX# <br /> A-1 8 L Z ( ) <br /> CITY i-ODI STATE GA ZIP 952-4-O <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: y_�� �� d DATE: (ZW02 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Jam. GIYI� Etd-- I"r- pe <br /> J,fAPPLICANT is not the BILLING PARTY proof of authorization t0 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 t0 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: SORFAcE At Z vuH��'RFA c-E G�NTM1MitvgTl At`+ RcF»R� RE�11=W <br /> COMMENTS: <br /> Keview�� t�-e <br /> 6Q a uZ <br /> APPROVED BY: EMPLOYEE#: 'LgZ DATE: f2-U)3 <br /> ASSIGNED TO: EMPLOYEE#: DATE:Date Service Completed (if already completed): SERVICE CODE: 31) <br /> Fee Amount: `� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />