Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property ( Is / / _ C� <br /> -4�7<Ure( 10 Y cS <br /> OWNER i OPERATOR CHECK If BILLING ADDRESS <br /> T/f.LIM SlJY1 4v'�JC FO P! <br /> FACILITY NAME / <br /> / C� OQ � <br /> SITE ADDRESS J� f GV � �J�� <br /> Street Number Draction <br /> Stree[Name cityZ{ e <br /> HOME or MAILING ADDR SS (If Different from Site Address) <br /> . � 7 Street Number Street Name <br /> STATE ZIP <br /> CITY �'� _ _ /_`_ / 9S2C�✓' <br /> LAND USE APPQLICATIOjN <br /> PHONE#1 O (� — 1 3U —G2— P�—OO <br /> (7) / S- 146 BOS DISTRICT r / LOCO.TJ0 ODE <br /> PHON/G)E#2 Exr. YI `—(1 <br /> (9 <br /> REQUESTOR <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> J 1 CHECK If BILLING ADDRESS �}'p <br /> a, <br /> � PHONE# EXT. �\ <br /> BUSINESS N.AME,',J _� <br /> (iflfl(/ FAx# <br /> HOME or MAILING ADDRESS ^-� Q ) Q <br /> CITY ? -_/7 ,y /�'.!� 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 projector \C�1 <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this applicatio and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S TE d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Yi DATE: �� 7 <br /> PROPERTY/BUSINESS OWNER❑ E /MANAGER J�L I OTHER AUTHORTZE6AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of 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 /> 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 is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: S CA_4-F-A(E S u i3S OL W-f C 0 0 <br /> COMME s: pp,YMEN-1 <br /> BEpENED <br /> '` ��U ,� . 6 2009 �,.rY•tJ JOAQUIN AL F� <br /> ��i�� H�i.TH <br /> pEPART EMPLOYEE#: V3`Z( DATE' <br /> ACCEPTED BY: ©t_(. r3 CCp(� <br /> EMPLOYEE#: S3 I—f- DATE.^-_-`� (o� <br /> ASSIGNED TO: (� r— p - - <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: '3 is PIE: 2-&03 <br /> Fee Amount: ob Amount Paid '%';Z4 0 , 6"� Payment Date a Ori' <br /> Payment Type <br /> Invoice# Check# y.g(, Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />