Laserfiche WebLink
JAIN JIJAIIUIIN I,VUIN IV E'INVIKUIN1VIEN IAL nEALIH LEYAKIIVIEtN 1 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> --r-- <br /> OWNER/ OPERATOR r q� <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME ' S1-� <br /> jj <br /> T ADDRESS-10 � DD � ,�� <br /> Street Number Direction A Street Name 4-- <br /> // <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t) V 3—2T3 EXT. I � 19#_ �2 A LAND USE APPLICATION# <br /> PHONE#2 Ay,- 6/ xT` /nye^� t'�/ (i� BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE FXQ�UESTOR <br /> REQUESTORb, p� 1 y �/�n ^�(� t t� I — — 4� , , L B CHECK If;BIL�LI;NGADDRESS <br /> BUSINESS NAME W l U'\VI J 11\1I// PHONE# EXT. <br /> 607 <br /> HOME or MAILING ADDRESS ^ / ,' J O I FAX# <br /> L4(w ( )465 -�37 -5 <br /> CITY S 952C75 <br /> 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,Star rds STATE and FERAL laws. <br /> APPLICANT'S SIGNATU DATE' 4 03 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> if APPLICANT is not the B/LI_/NG PARTY.proof of authorization to sign is required rime <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 enviromnentaUsite assessment <br /> 4—M W <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as as it is available.-rd-at e vmne.qme it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> M NTS: �.�//c�6- � t�-� T/lam✓S �l� �) L�/C��� �-!� L <br /> 1PtSIT- <br /> T <br /> GEiVED .�t�, r� <br /> APPROVED BY: - e AQ 1 #: E• �O <br /> ASSIGNED TO: PUBUCHtNbU : DATE: <br /> ONMENT <br /> Date Service Completed (if already completed): SERVICE CODE: D P/E: 02 <br /> Fee Amount: 1i Amount Paid $� _ Payment Date v <br /> Payment Type ✓" Invoice# Check# 1-S-L/ <br /> Received By: <br /> EHD 48-01-025 `.:t� ��C �GrxC <br /> t 2"���� ��� ��`-� �X�?"�'� SERVICE REQUEST FORM <br /> REVISED 6-5-02 �✓�� ano <br /> /<Z?iwlcr_/' <br />