Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 9(?5,1 PbW/*7rtZi �X o�z-zu-)2-LA <br /> OWNER/OPERATOR I b/ ^! A,I� <br /> L ,,,///ttt /V aJ l/t CHECK If BILLING ADDRESS <br /> FACILITY NAME f�t I f�y� /W <br /> SITE ADDRESS �/l/, II'`ter E� MacJ Vr lu V10,4) f b <br /> 11 .S� Street Number Direction Street Name Cit Zi Cod <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> /T r"W Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# - ^a VJ'D LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR(�,lv y avN U/ N4 fv� <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME Or MAILING ARESS / FAx <br /> # <br /> � •/ J �_/, �tv/Gmo/ "41) <br /> CITY STATE ) <br /> ziprT 7 <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 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. ,G <br /> APPLICANT'S SIGNATURE---)( - <br /> DATE: <br /> PROPERTY/BUSINESS OWNER 1JPERATOR/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 availatW�j <br /> at the same time it is <br /> provided to me or my representative. y, ^ ' <br /> TYPE OF SERVICE REQUESTED: ] V L SSS 7 AL S /V <br /> COMMENTS: <br /> 84AI APR ?8 ?p?0 <br /> •yE�NR�MF���N <br /> OEpAR MFNl <br /> ACCEPTED BY: EMPLOYEE#: DATE: /i 1 <br /> ASSIGNED TO: N EMPLOYEE#: DATE: LTJ <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: ��� Amount Pa; Payment Date nF4_1;1_0 <br /> Payment Type (! J Invoice# Check# 327 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />