Laserfiche WebLink
SAN JOAQUIIV COUNTY ENVIRONMENTAL HEALTH DLPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 �11 bb 3PLO oo <br /> OWNER/OPERATOR I ' <br /> /�+ I� VII a VC( Q O j. rn j r p I [ la I V q"Lv CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> at:os -'t",-4 Ln J ��oy <br /> SITE ADDRESS 730 S [?rhe^ <br /> Street Number I Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different froyrrtSiite Address) <br /> q[ ( S C r `v�✓t l� Street Number Street Name <br /> CITY STATE ZIP 9S a C�G <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 1 f� I v!'�O CHECK If BILLING ADDRESS <br /> BUSINESS NAME v� J 5 K PHONE# EXT. <br /> c�S �cc�.dc.�[A� ��� <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 4�ij� STATEeA ZIP �/(r l a� <br /> BILLING <br /> ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorizedagentof 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: . I,y�,�Z'-) V4 �&,j Zy DATE <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ Cl <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 to me Or <br /> my representative. p"MEN/ T <br /> TYPE OF SERVICE REQUESTED: 16 C5 Faod Vch,c,4 eon5,, fe&--, ]RECEIVED <br /> COMMENTS: <br /> JAN 0 9 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> }M-rH DEPARTMENT <br /> ACCEPTED BY: 01'e EMPLOYEE#: ©CO-7 DATE: lie <br /> ASSIGNED TO: S h EMPLOYEE#: S3(, DATE: ' <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: 1 a� <br /> Fee Amount: Amount Paid I Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />