Laserfiche WebLink
SAN JOAQUIN v-OUNTY ENVIRONMENTAL HEALTH Dr.,rARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER! OPERATOR , <br />#-\\e, aoat7/A, ‘rneinen?i CHECK if BILLING ADDRESS <br />FACILITY NAME <br />-1-01C05 Q\ P-el0C) Ak 'A LAG 3 LA. S 1= I OgV) <br />SITE ADDRESS 2_0103 <br />Street Number Direction Street Name City Zip Code <br />HOME or MAILING ADD_RESS (If Different from Site Address) -7 '3 Street Number <br />. C-i ee-V-eal..Q A-,re___ <br />Street Name <br />Crrv STATE ZIP ---.-, <br />PHONE #1 EXT. <br />(2CK1 ) '131-1- "" 2 -A-- <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR A <br />-Pk \ -ejovvAvA. lAw/inv/ CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />12-e <br />i.e 4V- pv EXT. <br />HOME or MAILING ADDRESS, <br />C1 et2i-tel e A-As? FAX # <br />( ) <br />Cm( STATE 01- ZIP ".1 5 -2,1 S <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 <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this;pplication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar <br /># <br />STATE and FEDER 4 laws. <br />TOR/ <br />ING <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNERIY <br />If APPLICANT is not the BIL <br />DATE: <br />ANAGER 0 OTHER AUTHORIZED AGENT 0 <br />RTY proof of authorization to sign is required <br />CM-05-101 <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmen* 'te assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and $4 4.me it is <br />provided to me or my representative. IV IV <br />TYPE OF SERVICE REQUESTED: 1--10 V alrk. as lvto,pech-DA, S <br />,i/.0 <br />ep 0 <br />COMMENTS: ‘9441 dr) 5 2018 <br />19441%;?//?6(r41 CO <br />`4.11/0-4,114/4 2: <br />ACCEPTED BY: .1 . ify\ osAk \AD EMPLOYEE #: DATE: <br />ASSIGNED TO: NC9}J'QC*0 EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: ao PIE: qo ps <br />Fee Amount: 4 ( 5-1. op Amount Paid Payment Date 7/' <br />Payment Type 2 e / Invoice # Check # Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003