Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTIEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 4,,r Au (P-7 <br /> OWNER/Of4ERATPBL r �t / <br /> i <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE'4DD�2E / I <br /> If�1r <br /> Street Number Direction Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> R) 6cx treet Number Street Name <br /> CITY n f l II(ISTATE ZIP <br /> PHONE1 /VExT• APN# LAND USE APPLICATION# <br /> oil 493 -0;�57 <br /> PHONE q33 <br /> w i`� �0 En, BOS DISTRICT LOCATION CODE <br /> CONTRA OfOR/ SERVICE REQUESTOR <br /> REQUESTO <br /> P CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE EXT. <br /> HOME Or MAILIN ADDRESS(95 <br /> t� FAX# <br /> CITY Y-71 d4A�A2 <br /> STA ZIP /lQ � <br /> BILLING A OWLEDGEMENT: 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 or my business as identified on this form. <br /> I also certify that I have prepared t ' application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand rds STATE and FEDERA ws. <br /> APPLICANT'S SIGNATURE: (� l DATE: ld <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ( BVIA <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. <br /> TYPE OF SERVICE REQUESTED: (.0 S 7— I J10, .A/ 6— PAYMENT <br /> COMMENTS: <br /> DEC 21 2010 <br /> SAN JOAQUIN COUNTY <br /> HATH DEPARTMENT <br /> ACCEPTED BY: i IL/F— t 42—j�-- EMPLOYEE#: O�24 DATE: r ftf a <br /> ASSIGNED TO: A/4.iOEMPLOYEE#: /�Q DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: rCl `_ P/E: <br /> Fee Amount:-#,i6� f1 t7 Amount Paid 3 b _ �-� Payment Date (?if 2 t O <br /> Payment Type ✓ Invoice# Check# (o z(�^ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />