Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER / OPERATOR � <br />I ✓ � �i /d�i / <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />ACCEPTED BY: <br />SITE ADDRESS 5'76G <br />Street Number <br />S <br />Direction <br />!lr¢I'I //ei� <br />Street Name <br />ASSIGNED TO: <br />72 <br />city <br />9°Sa <br />ZIP Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />a Sox .0?9y <br />Street Name <br />CIN�,eA1/N1 .. 031 <br />STATE C::4 ZIP 9/�F0 <br />•' <br />P E # ExT' <br />" <br />10fSeo - 5373 <br />AP <br />/ `3-aSSa-//� /.? <br />LAND USE APPLICATION # <br />_7r <br />PHONE #2 Exr. <br />( 1 <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR Lou�E ..�-1�vaEz <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME y,/� //D� /y� <br />COMMENTS:AYMENT <br />YIllh <br />I1e)ItT1>Z&/i/-v <br />�►��/' /� �" <br />HOME Or MAILING ADDRESS NO ./JO/r�[ w .�� <br />6 �`✓Y/ <br />ACCEPTED BY: <br />CITY J ADI <br />STATE /;# ZIP LJ!5�2/ <br />no <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 fo=. <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 JOAQUfN <br />COUNTY Ordinance Codes, Standards, STATE and FEDFR4 laws. / Q <br />APPLICANT'S SIGNATURE: DATE: <br />/ -914�j 11 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MA A ER ❑ OTHER AUTHORIZED AGENT h . / /TfT <br />If APPLICANT is not the BILLING PAR roof 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: <br />> <br />COMMENTS:AYMENT <br />YIllh <br />I1e)ItT1>Z&/i/-v <br />e� 21112 <br />jtwn nom, <br />RECE!'•:'ED <br />MAR 2 3 2012 <br />ACCEPTED BY: <br />EMPLOYEE #: 1731K., <br />DATE: 2 <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: ( <br />PfE: 7bo 1> <br />Fee Amount: Z,SU <br />Amount Paid <br />�Sp, " <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # 3311 <br />1 Received By: <br />EHD 48-02-025 SR FORM (Ggtden Rod) <br />REVISED 11/17/2003 / <br />