Laserfiche WebLink
vim SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID <br /> OWNER;OPERATOR <br /> ��{ � �^�,� k•—� CHECK If PILLWG ADD'<Esg <br /> FACILITY NAME 7 4 �o►", <br /> iAT <br /> SIFE ADDRESS 4 � CSM`—� � - �C♦�I� � &?! <br /> Street umber Direction t Name C Z' <br /> HomE or MAILING ADDRESS (If Different from Site Address) <br /> 1 Street Number SJrM Nara <br /> CITY STATE ZIP <br /> ,X t <br /> P'HONEJM APN# LAND USE APPLIc./mON# <br /> 1 <br /> PHONE E 60S DtSTR;CT LOCATION CODE <br /> ( �. 27(! 2 <br /> CONTRACTOR/ SERVICE REQUESTOR 04 <br /> REQU ES'TOR <br /> Cxecx if F31LLwo ADDRESS❑ <br /> BUSINESS NAME PHoHE# ExT. <br /> HOME or MAJUNG ADDRESS FAX# <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 ENVIRONMFN rAl.H?zALT11 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 tele work to be performed will be done in accordance wj JbAX JvA JIN <br /> COIINTY Ordinance <br /> C;an. and FEDER4t,laws. RECEAPPLICANT'S SIG < DATE: 2BOO$ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I iviANAGER OTHER AUTIIOitIZED AGENT❑ <br /> lit'Gaubm <br /> If APPLICANT iN not the BILLING PARTr,)goof of authorization to sign is required (41VV C;ipENTAL <br /> �16�1fy <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the pro &C at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmerntal/site assessment <br /> infomlation to the SAN JOAQUIN COUNTY ENvIRUNMENTAL HEALTH DEPARTL LENT as Soon as it is available and at the Sales time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> Ci01t1tENT5: l � 1 rcf'��� L fJG- � �� CJI'"' Gj�-I�� fid �.•-�►v�•� <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: J.�- DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: L-7,02,- <br /> Fee Amount: Amount Paid I9 Payment Date <br /> Payment Type Invoice# Check# Received By: ,� <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />