Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE spoill REQUEST # <br />OWNER / OPERATOR <br />()c (-51, \it.VCA-c-0'---- CHECK if BILLING ADDRESS <br />_FACILITY NAME \ <br />SITE ADDRESS 2t_ <br />Direction <br />€71--- \fv-,0 U)dk\-\ <br />Street Name 1 <br />Mo6e,s-k-o cp,- <br />City ) Zip Code Street Number <br />HOME or MAILING ADDRESS (If Different from Site Address) 16 16 <br />Street Number ____\_.--1,3\ ,-,. Street Name <br />CITY STATE <br />5 C <br />ZIP <br /> A- 9632_0 <br />PHONE #1 Exr. <br />(A ) 2q-co — tSt(OICA <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />ICAK-C)-- <br />CHECK if BILLING ADDRESS In <br />BUSINESS NAME PHONE # EXT. <br />( 10 CA ) 2_4-ca — <br />HOME or MAILING ADDRESS ‘2.... L..._ <br />-i.j.i \pc-, <br />FAX # <br />Cry STATE c jiclk ZIP 96 32_6 <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 applicati,on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STd and FEDERA s. <br />PPLICANT'S SIGNATURE: DATE: CYA — 06 2_0 ek. <br /> <br />PROPERTY! BUSINESS OWNER 0 OPERATOR ANAGER OTHER AUTHORIZED AGENT 0 <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. NT <br />TYPE OF SERVICE REQUESTED: MObi it )0() 11 ()e, cA-76() RECEIVED <br />COMMENTS: <br />SEP 05 20'19 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: OM co <br />S <br />EMPLOYEE #: qPiO DATE: /77/ I/ I <br />ASSIGNED TO: StOt[ EMPLOYEE #: DATE: /5 6 <br />Date Service Completed (if already completed): SERVICE CODE: 06e / P/ E) <br />Fee Amount:S 6;2_ o a Amount Paid --0 \. t , --- "=> --- Payment Date <br />Payment Type \./47 s', Invoice # <br />, <br />Check-# ' / Received By: f-t2,7 / <br />SR FORM (Golden Rod) END 48-02-025 <br />REVISED 11/17/2003