SU0003593 - Laserfiche WebLink

Home Browse Search

+ SAN JOAQUI:OUNTY ENVIRONMENTAL HEALTEPARTMENT SERVICE REQUEST Type of Business or Property PA FACILITY ID # PHONE#T SERVICE REQUEST # 1�tr� CITY STATE zip Lf ( ., 1i OWNER/ OPERATOR / 1 k' CHECK If BILLING ADDRES ACCEP:�::TED BY: FACILITY NAME �Arn>: � 41bOu� ©�� 'SuE ADD�R(ESS V O Ll n Ns�-- "m0e�k 10 CA 1 �37 t Street Number Direction tr N Date Service Completed (if alrea y completed): Gi Zi Code HOM at MAILINtADDRESS if4Different from Site Address) P I E: y2 tO 7 - Fee Amount: ; " Y�jj Amount Paid Street Number Payment Date Street Name CITY Onl n CA 1 k txl STATE zip Hyl PHONE #1 c�a 1 530-�g3� APN # X53—��J-05 Receive By: LAND USE APPLICATION # PHONE #2 EXT. c�10 1 53b -9,1x0 BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REOUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME PHONE#T HOME or MAILING ADDRESS FAx # CITY STATE zip BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all 'site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared COUNTY Ordinance Codes, Stand to be performed will be done in accordance with all SAN JOAQUIN APPLICANT'S SIGNATURE: DATE: 3 3a Q PROPERTY I BUSINESS OWNER RATOR I NAGER ❑ OTHER AUTHORIZED AGENT 11IfAPPLICA is not the41,; LLINGPA'R proof of authorization to sign is required Title AUTHORIZATION TO RELEASEFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environlnentaYsite assessment information to the SAN JOAQUrN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: ij PAY COMMENTS: Lf ( ., 1i C)E.ivzb APR 8 2 SAN JOA ENVIRONM C� HE TN DEPARN ACCEP:�::TED BY: EMPLOYEE #: ©�� DAZE; �C�fyrj0 ASSIGNED Tp:� EMPLOYEE #: d:9 O/ ( DATE: / Date Service Completed (if alrea y completed): SERVICE CODE: S� P I E: y2 tO 7 - Fee Amount: ; " Y�jj Amount Paid ` Payment Date Payment Type "_ate/ Invoice # Check # 6 $ Receive By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)