Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Is SERVICE REQUEST di <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />c0q-q-3 <br />HOME or MAILING ADDRESS <br />SERVICE REQUEST # <br />5k G0W 0-Z0 <br />OWNER/ OPERATOR U ��N Irk +(i <br />, <br />CHECK if BILLING ADDRESS ❑ <br />FACILITY NAME �Cp— Lt c <br />� n ,Go— <br />lJ�•�v <br />MINT <br />ACCEPTED BY: <br />SITE ADDRESS �37 T41�-l�luy- �� irl� <br />Street Number Direction/ Street Name <br />T� C� <br />�- <br />q Coq I 7 `6j <br />city Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />` J C1 I W Jq C'A-! .k;(— <br />Street Number <br />DATE: <br />Date Service Completed (if already completed): <br />Street Name <br />CITY <br />P I E: 2-3t I <br />STATE <br />CAq- <br />ZIP <br />of S`30 <br />PHONE #1 ExT.APN <br />( > 83 V- r3 (Y <br /># <br />Payment Date 3 ! 3 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />Check # <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # Exr' <br />HOME or MAILING ADDRESS <br />FAX # <br />( ) <br />CITY STATE 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 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 <br />COUNTY Ordinance Codes, Standards, STATE anal FEDERAL Ig <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER OPERATOR/ <br />If APPLicANT is not the BILLING <br />be performed will be done in accordance with all SAN JOAQUIN <br />DATE: <br />❑ OTHER AUTHORIZED AGENT ❑ <br />� 1 � l % -,coo C. <br />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 enq'nmentallsite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availablc' same time it is <br />provided to me or my representative. CENT <br />TYPE OF SERVICE REQUESTED: <br />U -ST <br />MAR <br />COMMENTS: <br />Sq 6 <br />N`JDgQUJN <br />NfLVR p pAR <br />MINT <br />ACCEPTED BY: <br />EMPLOYEE M �� Q,� <br />U <br />DATE: <br />ASSIGNED TO: <br />J <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: 2-3t I <br />Fee Amount: -4q3. �" <br />Amount Paid <br />3 , (�� <br />Payment Date 3 ! 3 <br />Payment Type j <br />Invoice # <br />Check # <br />Received By: C <br />EHD 48-02-025 SR FQF:M"(Golden`Rod) <br />REVISED 11/17/2003 <br />