Laserfiche WebLink
SAN JOAW. JOUNTY ENVIRONMENTAL HEALTH G-. ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Pvoluv.7� CQ CO-7'��C/44 <br /> OWNER/OPERATOR <br /> p�s f'ft C CHECK if BILLING ADDRESS 13 <br /> FACILITY NAME 13TGC IC 1 CIV I N C�f�s 9- 'S'rFb Y e <br /> SITE ADDRESS L- ' oycl`d C, . il'- S c)C IC-fi0 -f r 2-C' 2— <br /> Street Number I Direction I Street Name city Zii3 Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> IJ v " <br /> / AV V e- Street Number Street Name <br /> CITY STATE zip <br /> C-V�C �i V"b c J\ 11-S-61y <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (4og) SR?-- 7 7 <br /> [PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTR-ACTOR SERVICE 9EQUESTOR <br /> REQUESTOR /^ <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME <br /> (� PHONE# p D Ext. <br /> ��'OCICTDr ! CiA-S � ��Tb Y(:a_ ((i0 <br /> HOME or MAILING ADDRESS i(?Q/^ (7�` I�_� 4U FAX# <br /> CITY c! of STATE ZIP `t (r{� <br /> BILLING AO&CNOWLEDGEE10ENT: 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 wili be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and FEDERAL aws. n / <br /> APPLICANT'S SIGNATURE: � �A � �' � DATE: 16 03— <br /> I( y <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof 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 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 provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: � /Lt/(J �(/[�� /Y l�-C�cJ'�.J (�'�i `--� r• �L���f vC_�', �L1-�t l� /��,�/�7 �� <br /> oc Fi r <br /> sqN T <br /> �F Fav°qo� ��16 <br /> ACCEPTED BY: V1i!'a t, EMPLOYEE#: DATE: lU 5 i/'j Q�p �J N/V <br /> ASSIGNED TO: V Q ^ EMPLOYEE#: DATE: /Q h j, 4g � T <br /> Date Service Completed (if already completed): SERVICE CODE: n P/E:"Zo <br /> Fee Amount: y / Gj Amount /3? Q(/ Payment Date <br /> Payment Type Invoice# Check# Recei 4121y <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />