Laserfiche WebLink
SAN JOAQUI•COUNTY ENVIRONMENTAL HEALTHPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> ��S ink S -x(�ii o� l bt Ifo Z. <br /> OWNER/OPERATOR c.Jb K \ �' �` <br /> N CHECK If BILLING ADDRESS <br /> FACILITY NAME :�rAN K.,C C) `p S� <br /> SITE ADDRESS ��-7/ Direction tJ J� eoS n rl �'�' , 4 ve—, AA� 4e r I 2i Code q!UZ,6 <br /> Street Number Street Name Ci "� <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1xT• APN# LAND USE APPLICATION# <br /> (2a'i ) Z3at -C? �-7 <br /> PHONE#2E <br /> ,, (T BOS DISTRICT LOCATION CODE <br /> X03 C1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR A t�1 tJ <br /> 1\A ^ <br /> ( ( � Ser(l/ Cap It C -( CHECK if BILLINGADDRESSE] <br /> BUSINESS NAME JJJUUU PHZ#� 70 <br /> HOME Or MAILING ADDRESS S- w 0 F C 1 ( l 2W-, I 9 26 <br /> CITY �1 Yvo'`Cj j,7 STATE b Ch 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 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. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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, 1,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: <br /> COMMENTS: <br /> MAy 2 4 X004 <br /> SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL <br /> EALTH DEPARTMENT <br /> APPROVED BY: ` UW I k EMPLOYEE#: 'S3 -7 DATE: 5 <br /> ASSIGNED TO: � �� � .-.�''� EMPLOYEE : 3 DATE: �[ <br /> Date Service Completed (if already completed): SERVICE CODE: Ph: (J(g <br /> Fee Amount: ' C>4D Amount Paid "Z s b Payment Date 2 <br /> Payment TypeInvoice# Check# t f Received BY: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />