Laserfiche WebLink
SAN JOAQUII�T OUNTY ENVIRONMENTAL HEALT�EPARTMENT <br />4 SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME S <br />SERVICE REQUEST # <br />G <br />EXT. <br />F4000039 <br />sl,0c) 3ga2-I <br />tC) <br />CITY <br />CITY <br />STATE 0—, <br />ZIP CISZ CA 1 - <br />OWNER / OPERATOR <br />Pz— V <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />\ C'- m <br />'. ; C' - <br />SITE ADDRESS --2-)1� 1 <br />L� <br />'� 1 L YY, C, <-\ '2- I-. n- rte_ <br />�0 C\+� <br />G <br />).S2 RC1 <br />Street Number <br />Direction <br />Street Name <br />cityZip <br />Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />F <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT.qPN <br /># <br />LAND USE APPLICATION # <br />0 L:1,) � -� � :t) 2 �� <br />PHONE#2 EXT. <br />( ) <br />BO S DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />—.� L C— <br />CNECK if BILLING ADDRESS <br />BUSINESS NAME S <br />PHONE# <br />EXT. <br />HOME or MAILING ADDRESS E „r <br /><S s ,G <br />FAX # <br />(,'C i ) <br />y 2 - <br />CITY <br />CITY <br />STATE 0—, <br />ZIP CISZ CA 1 - <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 or <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, Standyrds,TATE and FEDERAL laws.iAPPLICANT'S SIGNATURE: o c L DATE: 0 t"1PROPERTY / BUSINESS OWNE ERATOR / MANAGER❑ OTHER AUTHORIZED AGENTIfAPPLICA T is nLLING PARTY, proof of authorization to sign is require Title <br />AUTHORIZATION TO EASE 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 an4A,(he same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />ACCEPTED BY: 0L- ( `,E <br />ASSIGNED TO: (?4rAni-1y4C-,-- <br />Date Service Completed (if already completed): <br />Fee Amount: X71, 0 0 <br />Payment Type <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Invoice # <br />Amount PaidiO-o2 <br />EMPLOYEE <br />EMPLOYEE <br />SERVICE CODE: -Iik <br />Payment Date <br />Check # `? <br />JAN y GQ�N-� <br />oNcoxM <br />SN' Nv�P o QPP�M <br />N <br />DATE: <br />DATE: j <br />P1 E: 23.08 <br />Received By: <br />SR FORM (Golden) <br />