Laserfiche WebLink
SERVICE REQUEST <br />Type of Business or Property <br />�, <br />D/VS' L:-5- Ac' ► r�vV�G 07K�rV JU�SOrV/ <br />FACILITY ID # <br />SERVICE RT <br />HOME or MAILING ADDRESS <br />FAX # <br />(Rt ) V7 1 — 30 221K <br />CITY STATE ZIP <br />C 71q <br />CjD � C.�� W C.k- <br />�hc 0007 Co Q $ <br />YEQU <br />�1�' . v <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS 0 <br />��10 S b11, Go Iv�(�ArIJ`i i � C✓ <br />FACILITY NAME <br />SITE ADDRESS <br />DATE: t'0 <br />ASSIGNED TO: <br />` <br />10 8 + L Street Number <br />Direction <br />Street Name <br />Ci <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Fee Amount: <br />? PJp I <br />Street Number <br />Street Name <br />CITY <br />��10t <br />STATE zip <br />s <br />ln.l GYLr1ocK1l <br />PHONE #1 EXT. <br />APN # LAND USE APPLICATION # <br />(q I 2<-i n <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ( CHECK if BILLING ADDRESS <br />�, <br />D/VS' L:-5- Ac' ► r�vV�G 07K�rV JU�SOrV/ <br />BUSINESS NAME <br />PHONE # Ems' <br />HOME or MAILING ADDRESS <br />FAX # <br />(Rt ) V7 1 — 30 221K <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 <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have preparedSOPETO <br />and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, StandFEDERAL laws. <br />APPLICANT'S SIGNATURE:�/ DATE: to �'Lo /o "C - <br />PROPERTY <br />PROPERTY / BUSINESS OWNER❑MANAGER 02 OTHER AUTHORIZED AGENT ❑ <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. PAYMENT <br />TYPE OF SERVICE REQUESTED: <br />�CVCI v t= v <br />COMMENTS: <br />OCT 3 t 2005 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: S <br />EMPLOYEE #: �� <br />DATE: t'0 <br />ASSIGNED TO: <br />EMPLOYEEM ;� � <br />DATE: <br />C <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />/ (� <br />PIE: Z.3p 8 <br />Fee Amount: <br />Amount Paid <br />0 0 <br />Payment Date O i 10 S <br />Payment Type <br />Invoice # <br />Check # 1 6 t q C� <br />Received By: N (, <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />