Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />CrZ OU —icq sa <br />OWNER I OPERATHR t <br />-Pa CHECK if <br />\ V-k 6s)z.0,0--z_._ O <br />BILLING ADDRESS 0 <br />FACILITY NAME ,s1"\\ \ c \A 0 fy: I( 0 <br />,) <br />_S <br />SITE ADDRESS <./.), 1, ,_....)Lit_i <br />Street Number Direction <br />7 4-)1 <br />Street Name <br />Majed-Ci <br />City <br />95 .5Y <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />( 1 0 CI VW•4C \X'4 .(- Street Number Street Name <br />CITY STATE ZIP <br />c o <br />PHONE #1 EXT. <br />(Cf16 ) 7OC/4/ 2 e cf <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR (- <br />\ Go (Yca c---c-- CHECK if BILLING ADDRESS 0 <br />BUSINESS NAME <br />Q \• 1 \ S C \-\ ° ( IC 0 S <br />PHONE # <br />rtu7)--my i aect <br />EXT. <br />HOME or MAILING ADDRES <br />OCCk S\1\(5'k <br />FAX # <br />CITY t 4c, STATE ro zu3c1 <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 />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 a nd FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/BUSINESS OWNER RI_ OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT 0 e <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. <br />, <br />TYPE OF SERVICE REQUESTED: \/ el, , ( by <br />COMMENTS: 9 <br />‘ <br />ii‘ <br />C'' \ -k CPktC4.4 <br />OV Vt 41 WV 0 yO‘f;‘013,1400 <br />*PP" -,3•1 t-) <br />ACCEPTED BY: cii II ( fiAltiq n (-,,i).-fic4/1-1. EMPLOYEE #: <br />vk- <br />fria <br />/6 /7 /(‘ <br />ASSIGNED TO: act( a r i ru ti hp? Clrf,i EMPLOYEE #: DATE: /6 f---7 //c, <br />Date Service Completed (if already completed): SERVICE CODE: j( 0 a, / PIE/ (17 0 3 <br />Fee Amount: 1 22 q Amount Paid '1?-9 Payment Date \ 0 ---t <br />Payment Type / A, ,:, , Invoice # Check # Received By:"---6,1 <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)