Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> IISoll FGI.U � I <br /> OWNER/OPERAT <br /> CHECK if BILLING ADDRESSf— rk(-+ *44 'UU L.AeVow e a c,(i✓eo /&6rer0.r <br /> FACILnY NAME -?0'6&' mini — McLr+ <br /> °F° 6CLS <br /> SITE ADDRESS r 5 I' -G I'fi L FlrvQ. . t„iv�k QC'20-7 <br /> Street Number Direction Street Name ^^C'1)U Ci `ZiJ Closde+ / <br /> HOME or MAILING ADDRESS (If Di fo f fronSite Address) to u'S <br /> Street Number C— Street No Fm <br /> CITY STATE CA <br /> Zip <br /> PHONE#1 EXT* APN# LAND USE APPLICATION# <br /> (toy) X73--!!7'1 II0 ® 230 . 11 <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> lzol <br /> ` CONTRACTOR/ SERVICE QUESTO <br /> REQUESTOR Luf n �vi Q l 1 CHECK if BILLING ADDRESS <br /> `� <br /> BUSINESS NAME d u e� l. fGviQ I n PHONE T 4-2D14 <br /> Lam/'4 En. <br /> HOME or MAILING ADDRESS FAXX#J <br /> 1krPJ Lu te,01 e. ` (2o ) b4--3S(os <br /> CITY STATE CA ZIP 45 U3 <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 applica' n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST and FE RAL laws <br /> JMJNJW�NATURE: <br /> PROPERTY/RTBUSINESS OwNERI OPERATOR/MANTAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign&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: <br /> COMMENTS: <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />