Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />'\ 1-,eU--) <br />SERVICE REQUEST # <br />5g-o67 q q <br />OWNER / OPERATOR . <br />OS e_ L ( all 0 c, <br />CHECK if BILLING ADDRESS <br />FACILITY NAME . <br />Ta ç 05 El 6 tiq Po <br />SITE ADDRES5 <br />/ C' i 1 ..vo.., Number I Direction <br />_ , 1 Aes'17--e, ; i <br />---- ' 1 Street 'Name City in; Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />/ e"/ / & r/tei ,(0/ t Street Number Street Name <br />Crry STATE ZIP <br />(4 <br />PHONE #1 Exr. <br />(21)3a <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR --r-- <br />105€.2_ L OCkta <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />-T?i (c),5 r ) LuciPo <br />PHONE # <br />(21-y) 37 <br />EXT. <br />-,2,40a1. 0 <br />HOME or MAILING ADDRESS <br />/ q/ 6 5 hffy C,-.7‘ <br />FAx # <br />( ) <br />CITY ) L - c. z.; i <br />STATE C ill <br />ZIP 95c2 q .. <br />2 <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 Of <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 and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER In OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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. PAYMENT <br />TYPE OF SERVICE REQUESTED: RECEIVED <br />F ----ND6 \I -Phis-J -e pr ) 5 per-h (-))1 <br />COMMENTS: DEC 2 7 2016 <br />-t-Z45541 7 I SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: -ad 0 EMPLOYEE #: DATE: j D (.7 , 47 <br />ASSIGNED TO: tiO0 fA C \ EMPLOYEE #: DATE: A)._ <br />Date Service Completed+ already completed): SERVICE CODE: PIE: /443 <br />Fee Amount: 1 -2D q - Amount Paid Payment Date <br /> <br />Payment Type Invoice # Check # Received By: <br />C'-.- DATE: <br /> <br />( <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)