Laserfiche WebLink
I <br /> I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Fr SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FQ l Gv�l 1��� L <br /> LL -Sfzm 7 <br /> OWNER I OPERATOR <br /> � ILLI <br /> D J CHECK If BNG ADDRESSO <br /> Lt RA) DPAI <br /> FACILITY NAME <br /> f <br /> 1 <br /> SITE ADDRESS 7 DO /�1 ' / wz"'� )e b•A R !r Nt7 j� F? �r <br /> Street Number Direction Street Name �l Ci ZI Code <br /> F. HOME or MAILING ADDRESS (if Different from Site Address) ��� "/ �OJV ��✓ <br /> F ! ) ,/ Street Numt�er Street Name <br /> CITY / /N�G� STATE �J,�f , zip <br /> PH0NE(#1 fir' APN# LAND USE APPLICATION# <br /> i PHONE#2 <br /> Exr. SOS DISTRICT 11 LOCATION CODE •: <br /> I } <br /> 1 CONTRACTOR/ SERVICE REQUESTOR <br /> FREQUESTOR CHECCK if BILLING ADDRESS0 <br /> 1 <br /> PHO E Ext.' <br /> BUSINESS NAME A I LI-O4/ <br /> FHOME or MAILING ADDRESS � FAX# <br /> 14-7 III-/// -r , <br /> CITY I STATE `. ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 form. <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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST and FEDERAL <br /> APPLICANT'S SIGNATURE: DATE: l� <br /> F <br /> PROPERTY/BuswEss OWN ERE] OPERATOR/MANIA �qf <br /> OTHER AuruottlzEA AGENT <br /> If APPLICANT is not the BILLING PARTY roof authorization to sign is required/ Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> F 'assessment <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite <br /> information to the SAN JOAQUTN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />` <br /> F provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: A'>'iVIE1E <br /> ,gG� �l> S UIrZ �G ./G l� j�� lrt�' RECEIVED <br /> JAN 18 2011 <br /> r'- <br /> SAN JOAQUIN <br /> TM <br /> EtWIRONMENTAL <br /> I y HEALTH DEPARTMENT <br /> ` ACCEPTED BY: EMPLOYEE M 2 <br /> � DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE:q1iC <br /> Date Service Completed (if already completed): SERIIICECODE: <br /> Pee Amount: `' Amount Paid Payment Date ' g 2,0 I <br /> 1 Payment Type Invoice# 1 Check# 7 Received By: <br /> EHD 48.02-025 SR FORM(Go en Rod) <br /> REVISED 1111712003 <br />