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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR <br /> / DA CHECK If BILLING ADDRESS <br /> FACIILL; NAME <br /> SITEADDRESS 339 („/ WEhT oQfPolO ROho /z/Pon! 9.S36G <br /> Stree[Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 60o uES7� / 711 AO AI/�. <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> 19,1 Po&I CIA <br /> PHONE#1 Exa APN# LAND USE APPLICATION# <br /> �ZOF) 5-75-- .429f API- 70 -3 9 PA - t3 vot 73 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> DD CHECK If BILLING ADDRESS <br /> BUSINESS NAME C-T� PHONE# ExT' <br /> + C-SAJ 4oz - <br /> rd- <br /> HOME orMAI LIN ADDRESS FAX# <br /> 0 6G -z <br /> CITY U Q�l,� STATE ZIP S <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 1 have prepared this appOation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,S r'and FEPFe9L laws. <br /> APPLICANT'S SIGNATURE: DATE: L 7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATO /MANAGER ❑ OTHERAUTHORIZED AGENT IO. <br /> If APPLICANT is not the BILLING PARTY,proof Of a� th riZation 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is provided l0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: 7W ( L T E �N <br /> COMMENT : ED <br /> - gglo � '11' , �I MAY <br /> 23 2017 <br /> �pN <br /> a+ 11 �o+J' JOAQUIAI <br /> COUt HF-ALT RpEpgENTAL TY <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: kI , EMPLOYEE#: DATE: <br /> Date Service Completed (if already com leted): SERVICE CODE: PIE: <br /> Fee Amount 4q5b <br /> ✓' Amount Paid Payment Date J Z3 <br /> Payment Type C Invoice# Check# 3 1 �� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />