Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />C —0 U(iY-- <br />FACILITY ID # <br />FA 002-nuA <br />SERVICE REQUEST # <br />SICZ-00 .12 3 /6, <br />OWNER / OPERATOR <br />Let C\ ' -2- <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br /> <br />SITE, 2.2_)t-n <br /> <br />V Street Number Direction 11 '\ nNN t? 0 Street Name <br />-b ,Ct-/q 0 0 <br />City <br />61 S0 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />nol,c) 1%4VS1 Street Number <br />' 11-0,4\Kfm \.2.6 <br />Street Name <br />CITY t— <br />( <br />fi <br /> MO\ <br />STATE , ZIP <br />133)0 <br />„Ruene#4 EXT. APN # LAND USE APPLICATION # <br />EXT. BOS DISTRICT ' LOCATION CODE <br />CA 0 DA —I a \ (60 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ..,,,\ ( '\, a t4,5 2... <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME .T0\10 if.yA scukka :\, tilawi PHONE # <br />01) (0)i—OT7 <br />EXT. <br />HOME or MAILING ADDRESS <br />IlUg jti k6I'M 1 ii, &/ <br />FAX # <br />( ) <br />CITY FQ CAOW\ STATE C f\ZIP g5-1)2_b <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 thi .aIiatiçn and that the work t be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standard's, ST TE an FEDERAL laWE3'. <br />APPLICANT'S SIGNATURE: _ <br />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 />1 jr. <br />TYPE OF SERVICE REQUESTED: rood vit tti'6 Tin S 196a1on Ile& kw" kN r cli/A-r , <br />COMMENTS: No, •".1.1 <br />0 0 ? <br />016 86441110.41Q <br />NEAELIPill10444f COUN <br />N °E.PAEN1-#1L 7)' Ardwrivr <br />ACCEPTED BY: al-teat Ailbe/tA lftri@ Ml.,041r) <br />EMPLOYEE #: DATE: 0 il (..0 <br />ASSIGNED TO: ....avitea,,inf2, )iohartes , EMPLOYEE #: DATE: N 0 n lp <br />i <br />Date Service Completed (if already completed): <br />4t., <br />SERVICE CODE: S G o tt ( P/,E: 10 b 5 <br />4, Fee Amount: A 131 Amount Paid /3(i. ()0 Payment Date /t/.// <br />Payment Type Invoice # Check # Received By: <br />goi <br />PROPERTY! BUSINESS OWNER 4.„ OPE, OR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT /S not the BILLING PARTY, proof of authorization to sign is required <br />DATE: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08