Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L�CPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> UaoY�"� ���boaa<--�L- <br /> OWNER/OPERATOR <br /> "'V .^^ •, V\ (iloy ` /��-2 44 <br /> FACILITY NAME CHECK If BILLING ADDRESS <br /> `, YC MCMV S s (v <br /> SITE ADDRESS 30 S C �t � -FoY't/l,t r,\ 1 S SA-6 cls �1� 9 5 2-o 3 <br /> Street Number Direction Street Name CI Zip Code <br /> HOME Or MAILING ADDRESS( If Differegfrom/Siete Address) <br /> 1 �� `� ff NV (f Street Number Street Name <br /> CIN : / I STATE ZIP <br /> Gh 53-2-6)4 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2-ON Z 2 <br /> PHONE#2 ! ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> /"! /a, �za -7� CHECK If BILLING ADDRESS <br /> BUSINESSUNAME CCS GY`( O� PHONE# EXT. <br /> HOME Or MAILING ADDR SS FAX# <br /> / <br /> CITY S O c I� 1 v V\ STATE ^ ZIP ' S 2-0 l <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 /> 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:CG/I-Yyfekl I4 /,G t'C,- 6,oy, le-z- DATE: <br /> PROPERTY/BUSINESS OWNER❑ 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 prOVA�tC�rile Or <br /> my representative. _ A.. rM <br /> TYPE OF SERVICE REQUESTED: AC,.0 � ��. �`�� �V D <br /> COMMENTS: 6 <br /> O <br /> x J�7� MAV JOAUII y CO <br /> IJN <br /> EAtryo�gRTAt ry <br /> ACCEPTED BY: / EMPLOYEE#: DATE: <br /> ASSIGNED TO: �/ ;f EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 6� P 1 E:/�� <br /> Fee Amount: ( /,;?0 Amount Paid / S U �� - Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> 07/17/08 <br />