Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY ID# SERVICE REQU ST# <br /> &f-Q,14 ;;e7J � V� (-' Rooi35b-z- <br /> OWNER/OPERATOR <br /> ` CHECK If BILLING ADDRESS <br /> p Dt k Vy� \h <br /> FACILITY NAME <br /> SITE ADDRESS 2$g5 1�a�t��r� Wo�t 5 -plc `t�r� 01 52 0l <br /> Street Number Direction Street Name Ci i Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1 C>'7— S Cf4^ �'OC►Q u 1 h C - <br /> Street Number Street Name <br /> CITYTATE ZIP <br /> S 95 201 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ► 1`131100"1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 1 ► p1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE 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 ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to ine 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 JOAQUrN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLINGPARTY,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. <br /> TYPE OF SERVICE REQUESTED: W <br /> COMMENTS: 50—r,KCe. <br /> o.v\ uv�lvwSeeG U 'C`�.0� <br /> Vwvw\1o¢C �uf Nut�h2 s�C Govv�v�.vr���/ G.4tv-%1te-,r. SQ -Iro �c4G� ��v+�� pv1 0�l\`�► <br /> (ki-74o) <br /> ACCEPTED BY: EMPLOYEE#: 9 dO C) DATE: /20 ' <br /> ASSIGNED TO: EMPLOYEE#: g OO O DATE: 3/2011-5 <br /> Date Service Completed (if already completed): SERVICE CODE: 0 O P/E: 'A7 A O <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />