Laserfiche WebLink
0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH�PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # SERVICE REQUEST # <br />R. G..T Pr L Pf S 0 G t ra <br />OWNER/ OPERATOR <br />BILLING ADDRESS <br />/'� o L V- STo 10 y r ` I�—C �/ n Tr` r `. <br />',tA , <br />CHECK If <br />FAc1uTY U t V- S� o s /�ZIC% <br />STATE C- A ZIP <br />SITE ADDRESSN_ <br />A, PA I- E C A <br />S 0 !9 Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />h -re'fL P R ( S F s T- <br />s-6 s- 6 4- <br />Street Number <br />Street Name <br />CITY 1Z 0 l <br />STATE C A ZIP s 3 <br />PHONE #1 Exr• <br />APN # <br />LAND USE APPLICATION # <br />( 57,0) 6 !r -4 B S O <br />PHONE #2 ExT• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />j / / A L -r—" <br />REQUESTOR ( C r r Ar 4,4- <br />t <br />CHECK if BILLING ADDRESSED <br />BUSINESS NAME/' 1 /r N L 1-a 4 4— 6. L KL E f-2 ( IX e r <br />PHONE # EXT.Vv V(0 <br />HOME or MAILING ADDRESS P. <br />0 3 O K toZ <br />p <br />FAX # <br />(4((p)31-3- <br />CITY ! , i ^ O � �+ � <br />STATE C- A 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 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 VEDERAL laws. <br />APPLICANT'S SIGNATURE: DATES:( ! ll , -Z�®LO } <br />��4 <br />PROPERTY / BUSINESS OWNER ❑ PERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Lp C V'•�► R A '� <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 available and at the same time it is <br />provided to me or my representative. n F�—= � Fc� fl \\ n FE� n <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />use 451�l NOV 2 7 2007 <br />�NVI('ONMENT HEALTH <br />sAEN°ADEPA TMENT PE�iM!T,/SERVICES <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE #:zblp DATE: lIff <br />Date Service Completed (if already completed): SERVICE CODE: P / E: 2 <br />Fee Amount: Amount Paid ` O D Payment Date o <br />Payment Type Invoice # Check # 2'. Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />