Laserfiche WebLink
SAN U . <br /> JOAQOUNTY ENVIRONMENTAL HEALTIOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Co pars 062 ,E <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> 'kT;k-T' <br /> F CILITY NAME <br /> SITE ADDRESS `\J �� S. A"Z— G ply 22-4 p <br /> % 2%A Street Number I Direction Street Name city Zip Cod <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 3p8 G. r ��}�QD �-1 r— looe— Street Number Street Name <br /> CITY STATE ZIP <br /> Dia `rtS T—X' -7 5 20'2— <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ <br /> `��r+ C' `CHECK If BILLING ADDRESS <br /> J <br /> BUSINESS NAME PHONE# EXT' <br /> q l to l¢to Cl-1 $2-10 <br /> HOME Or MAILING ADDRESS FAX# <br /> k',ZS C> C-c .tea c� �Y-.rte— (alb) 8 5cj6 <br /> CITY rCS—C> Lor O.�.f1-- STATE A-- ZIPS <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: (1(� `\,�o"A_�' �—Q..� o r�z DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT R. A C��2►�T <br /> IfAPPLICANT 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> sq <br /> 9P <br /> N <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: Z DATE: <br /> 4�2Date Service Completed (if already completed): SERVICE CODE: / P 1 E: <br /> Fee Amount: ��� �� Amount Paid3 \ S -- Payment Date \2 <br /> Payment Type Invoice# Check# S 3 U Received By: y <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />