Laserfiche WebLink
SAN JOAQ*COUNTY ENVIRONMENTAL HEAL*EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Goa Sfct �=� G >/1 SdZo6 (a3�3� <br /> OWNER/OPERATOJ� <br /> fv� CHECK If BILLING ADDRESS O <br /> FACILITY NAME /L / ` 5 D <br /> SITE ADDRESS /IL4/ 17 l/ I �rc�m o <br /> Street Number Direction <br /> Street Name <br /> HOME or MAILING ADDRESS (if Different from Site Address) city Zip Code <br /> Street Number <br /> CITY Street Name <br /> N rvi sTC ZIP C� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# J <br /> PHONE#2 Exr. <br /> 7 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> ra m D c�✓ CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Uor ee fro Ui ✓sc.>° 0r?d <br /> HOME or MAILING ADDRESS FAX# <br /> x 1-76-71 LJ 37- 35 7 <br /> CITY n <br /> STATE Com\ <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 DIPARTMEN-t hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQLn'. <br /> 0A N I1 01-dilk"We Codes,Standards, S I-ATf-. and FEDC-RAt, laws. <br /> APPLIC'ANT'S SIGNATURE: �� DATE: <br /> fRO1'ERl'1-/131 sl%i'ss ON NEIL❑ 0I'E12AT0R/.N-IA\AGER ❑ O'1'l1ER r�C'rHORIL.ED:�GEV"1'®_ ,/1-�.� C 'E—U�" <br /> l/.11'1'0(-':I,\[ is not the BILLIAG PART),proof of authorization to sign is required f� 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 CUIiNTY ENVIRON!N1I:N"I-Ai.HEALTH DEPARTNIEN T 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: 2 PAYME <br /> COMMENTS: <br /> IV <br /> JUL 19 2011 <br /> SANVIRON COUNTY <br /> FNNME TN <br /> H�.TH DEPAR <br /> ACCEPTED BY: EMPLOYEE#: /_ DATE: <br /> ASSIGNED TO: f EMPLOYEE#: lP DATE: <br /> i Ll <br /> Date Service Completed Iready completed): SERVICE ODE: / p 1 E, <br /> Fee Amount: Amount Paid .�� Payment Date �� <br /> Payment Type f Invoice# Check#�� <br /> Ile By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />