Laserfiche WebLink
SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> w ,ne, r SYzoo -7ulg5 <br /> OWNER/OPERATOR <br /> Lon-1 �A eft CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Ma, c-�\i v` <br /> SITE ADDRESS --70 G � r Pe- e-V- RA , of b 95ZZO <br /> StreetNumber I In n S[reet Name CIty Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (ZDq) 0 60.3- 1000 --II '� v <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> 202) vl0 -59Z� - �na�Lq,n <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR n ^^ / `_ <br /> l�J" \ (�/ C�Jf�+V CHECK If BILLINGAODRESS <br /> BUSINESS NAME PHONE# En. <br /> HOME Or MAILING ADDRESS FAX# <br /> I ( ) <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 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 I d FED RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ ERATOR/MANAGER Ef OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i5 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 above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 Soon a5 It IS available and at the same time It IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: RECEIVED <br /> FEB 08 2017 <br /> M F- ESl.�/er <br /> &.0 SAN JOAQUIN COU <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid �,7 9- co0 Payment Date :L /-it 7 <br /> Payment Type CSL Invoice# Check# lL4 -j S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />