Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of opin s or Property FACILITY 10 S SERVICE REQUEST <br /> CA-Aa p -3 u 6 .7i 2 <br /> L Liu <br /> OWNER I OPERATOR . CHECK N 13 <br /> FACILITY NAME <br /> SITE <br /> MS 31,1 w..er OnO, <br /> er <br /> HOME o (M roM Site Address) <br /> w <br /> CITY STATE zip <br /> APN s LAND USE A*vijcAnoN s <br /> PAm 02 Exr. BOS OnTRIcT T7� <br /> ( 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REWIESTOR CMECK If ❑ <br /> BUSINESS <br /> 1 <br /> Clnr STATE LP Ck <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent same, <br /> acknowledge that all site and/or pro' fic ENvRoNwNTAL HEALTH DEPARTWNT hourly charges associated with this or <br /> activity will be breed to me or m611—as' i form. <br /> 1 also certiry that 1 have prepart that work to be perfom�ed will be done in accordance with all SA JoAOUINCouNTY on*wnce Codes,Sf aws. <br /> r <br /> APPLICANTS SIGNATURE •�j C• DATE: � <br /> PROPERTY I BUSINESS OWNER❑ OPERATO (ANAGER Or THORlZED AGENT ta - �"• <br /> ff APPLICANT is not the BrNLwo PARrY.Proof of aNrthoRzatfon to sign is required F Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, 1, the owner or operator cates <br /> the property loat above <br /> site address,hereby authorize the release of any and all results,geotechnical data andf r envirorimentallsits assessment' <br /> to the SAN JOAww COUNTY ENVIRONMENTAL HEALTH DEPARTM[NT as soon as it is available and at the same bme it is prov t *E&T <br /> my representative, NED <br /> TYPE OF SOME REQUESTED: L' k � O �fw <br /> COMMENTS: g /,.�/,�` '^6�y�jL 4-H M�R0��/ W� <br /> (!N• NT r-t'�y� Vtfll DEa TyeINT <br /> ' 1 666 <br /> ACCEPTED BY: EMPt.OYEE# / 0 DATE: S-1-7/1 <br /> AsswrrED TO: i .�rtiN� EMPLOYEE NF: r, DATE: <br /> Date Service Completed (if already compieted): smm CODE: <br /> Fee Amoun 3)S- Amount Paid 3 75;0 Payment oats! s(y 3 <br /> Payment Type Invoice Checks d�b7�� Received By: <br /> EHD 49.02.025 SR FORM( en Rod) <br /> 07117108 <br />