Laserfiche WebLink
-T,- his he"ek Is <br />SAN J69uIN COUNTY ENVIRONMENTAL HWH.DEPARTMENT <br />SERVICE REOUEST. <br />Type Business o0roperty <br />PAYMENT <br />- FACILITY Ib # <br />SERVICE REQUEST # • _. <br />R6`6 61 L <br />OWNE / OPERATOR <br />I <br />1 <br />CHECK if BILLING ADDRESS O <br />DATE: Y 2 %Q tr <br />ASSIGNED TO: `y ,til <br />SITE ADDRESS <br />Street Number <br />Direction <br />O KU 1 `L 4 <br />Street Nime <br />cityZi <br />ode <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Nu bet <br />Amcurit Paidt�°% <br />Street Name <br />CITY <br />Payment Date �� a <br />STATE ZIP <br />PHONE tai <br />ExT• <br />APN # <br />LAND. USE APPLICATION # <br />PHONE fit <br />f ) , <br />ExT. <br />BOS DISTRICT LOCATION CODE <br />REQUESTOR <br />BUSINESS NAME,. A' <br />CONTRACTOR 1 SERVICE REQUESTOR <br />CHECK if <br />rY1II / LI / fJJ (t Dill �I <br />PNONE <br />HOME or MAILING ADDRESS ��/r�% FAX# <br />lw f r � <br />CITY STATE ZIP�7 <br />l BILLING ACKNOWL DGEMENT: 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, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE:hL PATE: ate► z�;6 r <br />Pilo ILERTY, I BUSINUSS 0WNEtt_ = `= := Qfw£ii �Ta�fa 1 NAG4ItD_ :_- OTMeR,AvTpojug-;Fo AGENTV A41 <br />If APPLICANT is not the BILLING PARTY. proof of authdrization to sign is require. Title <br />AUTHORIZATION TO RELEASE, INFORMATION: When applicable, I, the owner or operator of the propet•ty located at the <br />above site address, hereby authorize the release of any and all results, geotechnical dataland/or environmental/site assessmen6 <br />informatioft 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 />/� <br />TYPE OF SERVICE REQUESTED: Li S .T 91--47T-�-0 7Gt `T <br />PAYMENT <br />COMMENTS: <br />DEC 19 2011 <br />A SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMWr <br />APPROVED BY: d L f CJ f <br />EMRLDYEE #: ?j <br />DATE: Y 2 %Q tr <br />ASSIGNED TO: `y ,til <br />EMPLOYi E #: <br />DATE: . Z�( `� It <br />Service Completed (if alreadycompleted): <br />SERWCECODE: <br />PIE: 36 <br />Fee Amount: ? 7S" t <br />Amcurit Paidt�°% <br />Payment Date �� a <br />Payment Type <br />Invoice # <br />Check # . �(� <br />Receive By <br />EHD 48-01=025 <br />SERVICE REQUEST FORM <br />