Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A Q/ <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS <br /> R• ZaufBu«r�e <br /> FACILITY NAME <br /> SITE ADDRESS /�4 S� ��jT TOKA CVZ-ONy/ <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) /20-// I5A 5T L/✓E e2A K ROA-f) <br /> Street Number Street Name <br /> CITY �O D / STATE C�-A ZIP 475 -fO <br /> PH NE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 09> 20 3 -939 06 -ZY0 - 20 P,4-o41-4173 PA -a7•03 ,Z <br /> PHONE#T EXT. BOS DISTRICT LOCA CODE <br /> CONTRACTOR/ SERVICE REQUESTO <br /> REQUESTOR > <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME C`rl PHONE# ' <br /> CkES/vE Co/l/1 u�ri.� -/ O <br /> HOME Or MAILING ADDRESSD x FAX# <br /> CITY <br /> (llZ LO�-/�G STATE A ZIP y.53BI <br /> , <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,ST and FED L laws. �f <br /> APPLICANT'S SIGNATURE: DATE: /&7. <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR NIANAGER ❑ Ithorization <br /> THER AUTHORIZED AGENT, <br /> If APPLICANT is not the BILLING PARTY,proof of a to sign is required Tule <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: SO/G s a/ %AL3/V/ % s%ew E Vi E VV AYMv T <br /> COMMENTS: //16/ '�//67G / <br /> �0 �/I/5 <br /> D'� /'-7 <br /> _ OCTr 3� <br /> / R�z7 i2E v/calm r�0 / 2007 <br /> SAN JOA <br /> QUIN`` <br /> ENVIRONMENTAL <br /> HEALTH DE ART ENT <br /> ACCEPTED BY: l., L i U C( _ EMPLOYEE#: 3 L DATE: O Z✓ O <br /> ASSIGNED TO: l G U. EMPLOYEE#: �� k4 DATE: 23 Q 7 <br /> Date Service Completed (if already completed): SERVICE CODE: 2 P I E:-2,0 o <br /> Fee Amount: t Amount Paid �� Payment Date 104 a <br /> Payment Type ✓ Invoice# Check# Received By: (46 <br /> EHD 48-02-025 SR FORM'(Golden'Rod) <br /> REVISED 11/17/2003 <br />