Laserfiche WebLink
W28 <br /> / AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> l I K SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Relad -00± <br /> �00 -7 10&-=1 <br /> OWNER/O ERATOR <br /> r�� � � t^i , I�� + CHECK If BILLING ADDRESS <br /> FACILITY NAME 1 D r <br /> SITE ADDRESS 520 SlChe"Kee Ln W1 -e 101 Lod r g52ya <br /> StrlleJJel Number Direction Street Name City Zip Code <br /> HOME Or MAILINGADDRESS (If Different from Site Address► 151--30 /'t/`II e i/�/,t Or * f3- 1 1 <br /> Street Number goc( C�Y taw t Street Name N <br /> CITY STATE CA <br /> ZIP q//5o <br /> PHONEo##1 Ex-r. APN# LAND USE APPLICATION# "I <br /> (qa5) 90s ggoo �f52-� d���c�u►� <br /> P ONE#2 EXT• BOS DISTRI T LOCATION CODE <br /> 14 40D LIM �t <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORyo �� tdds % �� CHECK if BILLING ADDRESS <br /> -01,119 <br /> BUSI SS NAMEXT. <br /> cot s 01 ScoLi/I fS (H a5) (off y �� `f�9'l0 <br /> HOME or MAILING ADDRESS. FAX# <br /> Pf dA 8 (8 y) g3oi- 833c) <br /> CITYo, STATE /! ZIP a t�5(„Q) <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. u <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERAT ANAGER ❑ OTHER AUTHORIZED AGENT Bt�lrI � W <br /> ig <br /> R/M <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title R M N <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property o1� lea—, ���rr <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or env iron mental/sIte ssess Ni4 <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the%s r 415 i* <br /> provided to me or my representative. `�NJ JJ 11 �8 <br /> TYPE OF SERVICE REQUESTED:"�'��/e�olnh1� 1 Yls e1+'0V] f&r ►Yy �o��`,S/ I `�D � r��LTti -ft OU fry <br /> COMMENTS: 1,655 -W AY l WV S F e e4 O-F ,)r e ' 19A t K A JeA FDLW , rMF <br /> ' e S�V1d DIT i'na1 (i'cev�s� to m 6[4+-ern-'L Gam' -the <br /> I'D Ales !Gc e ' we- w( N s��l ori mal �a f o& stor <br /> InG�I l� � P 9 <br /> ACCEPTED BY: EMPLOYEE#: DATE: rf, IS <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1 _ .l� <br /> Date Service Completed (if already completed): SERVICE CODE: -�.2 P I E: '�O <br /> Fee Amount: 45( <br /> Amount Paid vU Payment Date✓ <br /> Payment Type (!XInvoice# Check# �/33 Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />