Laserfiche WebLink
SAN JOAQU COUNTY ENVIRONMENTAL HEALTREPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />CHECK if BILLING ADDRESS-s;:�NC•�1 N 6, N�aF�tZ�. <br />BUSINESS NAME <br />A'S EN i fJ �fZt r` J lrc <br />PHONE # ExT. <br />�6l .ZS"0-- `i O 0 <br />HOME or MAILING ADDRESS <br />^r <br />ZS --'T/.J-1> C IV Z10. cv—` irl. ). <br />� <br />FAX # <br />) <br />OWNER / OPERATOR <br />E] <br />Tisomo t-tft0-VA--41W& <br />CHECK if BILLING ADDRESS <br />CZ <br />F T TY S-Smo v <br />SITE ADDRESS J10 <br />��,Iy�µA� 1�rtJ fc— <br />t _ �l <br />ISTCit <br />T"' <br />�7LTJDirectionStreetName <br />EMPLOYEE #: <br />w <br />DATE: -7/2 / <br />ASSIGNED TO:V <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />I q�- Z2- <br />Date Service Completed (if already co pleted): <br />Street Number <br />Street Name <br />CITY ` nl 1�O \ O <br />ISS <br />STATE -Tbc ZIP <br />PHONES #1 ExT• <br />Lzlo) &ZG - ZZ <br />APN # <br />0 <br />Payment Date —41- <br />� <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />BOS DISTRICTJ� (� <br />LOCATION CODE <br />Received By <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />k 1>t.G F <br />• <br />CHECK if BILLING ADDRESS-s;:�NC•�1 N 6, N�aF�tZ�. <br />BUSINESS NAME <br />A'S EN i fJ �fZt r` J lrc <br />PHONE # ExT. <br />�6l .ZS"0-- `i O 0 <br />HOME or MAILING ADDRESS <br />^r <br />ZS --'T/.J-1> C IV Z10. cv—` irl. ). <br />� <br />FAX # <br />) <br />CITYC/ <br />-01600 <br />STATE ZIP q ? di <br />/00 <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 to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDE s. <br />-7L APPLICANT'S SIGNATURE: - DATE: <br />PROPERTY / BUSINESS OWNER OPERATOR ANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is not the B/LL/NGARTY 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 t0 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: 0416-4 \ f t.J Orr X7,,%,tJS- <br />k 1>t.G F <br />Tv pts IWAYMENT <br />COMMENTS: <br />RECEIVED <br />JUL 3 0 2013 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: �t ^' �-1 ! 1 i _ <br />V UQiy�`�y J <br />EMPLOYEE #: <br />w <br />DATE: -7/2 / <br />ASSIGNED TO:V <br />EMPLOYEE M <br />I q�- Z2- <br />DATE: <br />Date Service Completed (if already co pleted): <br />SERVICE CODE: ` 7� P 1 E: a�rf� <br />Fee Amount: 7 _�_ <br />Amount Paid <br />� 0 <br />7V0 <br />Payment Date —41- <br />� <br />Payment Type <br />Invoice # <br />Check # 7 <br />3 <br />Received By <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />