Laserfiche WebLink
SAN JOAQ 4 COUNTY ENVIRONMENTAL HEAL*EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GRS <br /> STA 71UrJ co NVEN1ii - F 0 0 0 o CT 9'L- �0 7050 <br /> TakEOWNER/OPERATOR <br /> JLI 1 Q,.\ CHECK If BILLING ADDRESS <br /> FACILITY NAME A <br /> SITE ADDRESS S CM <br /> I'I E A v E iMA'�T ECS 9 5"�"5 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> J;1- COOA- Lit ' Street Number Street Name <br /> CITY STATE L A ZIP 4 33 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) -19:5 I O �2 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR J A�S&� – �' � J�SSS c� �U E () \ <br /> 1J Y L��L`L-k;Ut✓l�INL) CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# / EXT. <br /> Jesse A EzKoL-1-- vM ,>vz 10j 6'-s - C) ll� <br /> HOME or MAILING ADDRESS FAX# <br /> I1©O S. MAI1s `�T(LrL, T (2')R ) 'LS-- 00 <br /> CITY �� A��—r�CA STATE C A ZIP <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 ENVIRONNIENTAL 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 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: Aawma DATE: <br /> X4Re /BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 anc�,3t t�i��Ame tim it is <br /> provided to me or my representative. AWme <br /> , <br /> RECEIVED <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: SEP 16 14 <br /> A-^'t� ct Uwe L SAN JOAOUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DLPARTMENT <br /> ACCEPTED BY: l _ EMPLOYEE#: DATE: <br /> ASSIGNED TO: (/I w EMPLOYEE#: DATE: ll 1 l <br /> Date Service Completed (if already completed): SERVICE CODE: 07 k PIE: <br /> Fee Amount: \ Amount Paid 1-30. Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />