Laserfiche WebLink
SAN JOAQtj,,,. COUNTY ENVIRONMENTAL HEALTH L-PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Sr' Pit 0 'Olt Q(j ct) <br /> OWNER/OPERATOR <br /> 1c)V C n O Y� �� CHECK If BILLING ADDRESS <br /> FACILITY NAME I r� <br /> P �OQS o LL UCY-) L C_ <br /> SITE ADDRESS ��QC� (,KrTL7►� G�Zn <br /> f3 } <br /> Street Number Direction Street Name CI'' 11 Zi Code <br /> ME MAILING ADDRESS (If Different from Site Address) l Z �j`i � T-0 <br /> ✓� C <br /> 2 Street Number Street Name <br /> CITY, STATE ZIP <br /> S't�CX'-M� «A �'I -�ZeSL <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2,0cv 2-35 6:, 2C2— a <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) 6b I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> IL <br /> RIQUESTO�7R <br /> c- f�vl ip� \f ^ C CHECK If BILLING ADDRES <br /> B NESS NAME �E-� 01 PHONE# EXT. <br /> (() Q-(. 1 W2 Z)LL 0o-1 �C !�--C,L� <br /> HOME or MAILING ADDRESS FAX# <br /> � <br /> CITY��� J STATE C ZIP OZ <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,STATE and F DERAL Taws. <br /> APPLICANT'S SIGNATURE: n- DATE: <br /> PROPERTY I BUSINESS OWNER ICF OPERATOR/M IMAGER 1:1 OTHER AUTHORIZED AGENT 1:1If APPLICANT is not the BILLING PA proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, t, 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It is available and at the same time It IS provldeCib�e Or <br /> my representative. YJ <br /> TYPE OF SERVICE REQUESTED: USE %1f;4 d <br /> COMMENTS: yc� o�a -er hsN�OgQ� <br /> �9�Tyo�qR�o� � <br /> MFN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: I EMPLOYEE#: DATE: l ,✓'�.- J <br /> Date Service Completed (if already Completed): SERVICE CODE: P'/E: > <br /> Fee Amount: CD AmountPaico, �b Payment Date -3// <br /> l <br /> Payment Type `� Invoice# Check# Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />