Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# 1 ' <br /> — e�� 5� �5 7-7 Y 1 <br /> OWNER I OFER/17OR <br /> C.'IECA if BILLING AD DRE is <br /> f i1CILITY(\IA'!!4 G , <br /> G i�,�7--7 <br /> Q <br /> SITE ADDRESS <br /> Stree Number Direction .roet Nemo <br /> �l-t,.vlE Or- -ING ADDR=SS (If niff.,rent from Site Address) <br /> _\-5 -/_,__�_n nil �Z Street Number Street Name <br /> i IT' T STATE ZIP �}��•� ^ I <br /> — L �a 9 sem) i <br /> PHONE#11 EXT. APN# LAP!D USE APPLICATION# <br /> PF)NE#? EXT. BQS DISTRICT LOCATION CODE <br /> i ( } <br /> REQUESTOR • <br /> C,u �,y�U� CHICK If 61LLING ADDRESS `. <br /> BUSINESS NAME (� 1 1 ` PHONE# EXT. <br /> 1 I t0(1) 'i23 3 �3ti3 <br /> HOMEc or <br /> MAILING ADDRESS FAX# <br /> CITY 1 STATE /"ct ZIP C}� <br /> BILLING ACKNOWLEDGEMENT: i, the undersigned property or business owner, o4p-erator 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, ST4TZa �*ERAL laws. <br /> APPLICANT'S SIGNATURE: Q7Yv L4✓\ DATE: <br /> PROPERTY I 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 abure <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 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. <br /> TYPE OF SERVICE REQUESTED: t C L PAYMENT <br /> COMMENTS: t L-------RECEIVED <br /> SEP 12 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED By<j EMPLOYEE#: DATE: <br /> ASSIGNED Tr,: ;�/ EMPLOYEE#: DArE: <br /> D,.ie Servic,--Cirmr lete�l `Tat. �dy completed): SERVICE CODE: �[}—E:—` 6lJ <br /> da <br /> Fee Amouni t� �w Amount Paid - I ; "i -_ Payment C� �� ! <br /> % : . . �_ <br /> Payment Type Oil's V\ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />