Laserfiche WebLink
A( } SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SCl ao I !\)tv-) 52�� <br /> OWNER/OPERATOR <br /> I OC � QC �a�V ^ CHECK if BILLING ADDRESS <br /> FACILITY NAME 41S rCDu,tna,,,, TQr <br /> SITE ADDRESS '� 1 H 4 2 G q ir t or+ W GLI1 I"`4l'i fe-CA �S3�j� <br /> Street Number Direction �'T f Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (2w Lf fob - S91-10 '29// <br /> PHONE#2 Err. BOS DIU IC�T� LOCATTION CODE <br /> ( ) v —L <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR -�\I I 403 - 3301 <br /> 'f 03 "- 3 3 0 t CHECK If BILLING ADDRESS <br /> BUSINESS NAMES \— PHONE# ExT.u►^ S�q �i✓` C U v.�.�`1 4�'c.tL �� L-c�� 2c� �1�- -�'f(v"? <br /> HOME or MAILING ADDRESS _ FAX# <br /> CITY � STATEC/�- zip gSzU <br /> CZ <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 <br /> or 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 Coder,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �/ DATE: <br /> . -7/// <br /> PROPERTY/BUSINESS OWNER❑ OPER TOR/MANAGER 6d OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is,not ILLING PARTY proof of authorization to sigtt 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 /> inforniation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at A <br /> e same time it is <br /> provided to me or my representative. Ay <br /> 111WTYPE OF SERVICE REQUESTED: (►F <br /> COMMENTS: ` <br /> RO UI C <br /> h r/y ��H� <br /> MFNT <br /> ACCEPTED BY: EMPLOYEE#: i I DATE: <br /> ASSIGNED TO: EMPLOYEE#: Q T DATE: <br /> Date Service Completed (if already comp) ed): <br /> SERVICE CODE: PIE:' <br /> It <br /> Fee Amount: Amount Paid/$'/—V-D-D Payment Date 7 <br /> Payment Type Invoice# Check# I Rec ived By: <br /> EHD 48-02-025 per' SR FORM(Golden Rod) <br /> REVISED 11/17/2003 yv- i <br />