Laserfiche WebLink
SAN JOAQUini COUNTY ENVIRONMENTAL HEALTH iimPARTMENT <br />SERVICE REQUEST <br />Ty of Business or Property <br />CET \lem707--- <br />FACILITY ID # <br />.1,,,00-z_c-ti--k ZD <br />SERVICE REQUEST # <br />52 pageos g <br />OWNER / OPERATOR <br />'<01-2.-9 L (5 ,--) A-A IS' <br />CHECK if BILLING ADDRESS <br />FACILITY NAME 1—D 00 1CZOCV--0— <br />Street Number Direction <br />SITE ADDRESS <br /> <br />Street Name City Zip Code <br />HOME Or MAILING ADDRESS If DiffLent from Site Address) <br />'2 7, <br />A <br />- 4 16-tE i'-i-)---' t\--vk Street Number Street Name <br />Crry STATE ZIP c-6-1-DC_AT cds, <br />I) /4 t9i S7 (-- Li <br />PHONE #1 <br />(7O <br />„ <br />(1 <br />EXT. <br />(0 61 <br />APN # LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR (,c,),,..) U 0 vs..1 IA4 A (NJ CHECK if BILLING ADDRESS <br />-- BUSINESS NAME ..liTy-r) 7) ' S ' --i-) 66 C PM5,4 <br />( Lt3 r <br />9. (;) 1 .... EXT. 25 0 2, .c.... <br />HOME or MAILiNG ADDRESS 2214 L A- ). — r te 6i i <br />CITY a..k.„....„,..., <br />c x <br />AVe — <br />FAX it <br />( ) <br />STATE CA___ ZIP <br />BILLING ACKNOWLEDGEMENT: I, the unde <br />acknowledge that all site and/or project specific <br />activity will be billed to me or my business as id <br />ned property or business owner, operator or authorized agent of same, <br />IRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Of <br />d on this form. <br />Ty <br />NT <br />I also certify that I have prepared this <br />COUNTY Ordinance Codes, Standards, <br />APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER <br />If APPLICANT IS not the Bi <br />nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br />FEDERAL laws. <br />vi <br />DATE: <br />ATOR / MANAGER <br />OTHER AUTHORIZED AGENT El <br />ING PARTY proof of authorization to sign is required Title <br />pp ca . <br />ST. E • <br />/8 <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. <br />TYPE OF SERVICE REQUESTED: , <br />PAYMEN <br />COMMENTS: awl t), w\mag\1043 RECEIVE <br />JAN 0 8 201 <br />SAN JOAQUIN COW <br />E NVIRONMENTAL <br />HEALTH DEPART F <br />ACCEPTED BY: \\1 . yyk,(SAV1 C EMPLOYEE #: DATE: <br />ASSIGNED TO: Cy\ -F._ )44 12c_A tAi.\--40/.... EMPLOYEE #: DATE: 110- g—‘1 <br />Date Service Completed (if already completed): SERVICE CODE: tpco ( / PIE/ ItaDS <br />/ eAr Fee Amount: <br />1 1 a. <br />Amount Paid Payment Date <br />Payment Type \ ' ( c 4 Invoice # Check # <br />V - - <br />Received By: / <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />07/17/08