Laserfiche WebLink
SAN JOAQ*COUNTY ENVIRONMENTAL HEALTISEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �s s-�-rc� ►J o 3el'07Z <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 1A `` t <br /> �3 S VV C��p-ut Lime. Tv cey 9s37 <br /> Street Number b <br /> Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. PN# LAND USE APPLICATION# <br /> A <br /> PHONE#T ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> „e-L'9Lt n rl�U` t CHECK If BILLING ADDRESS <br /> BUSINESS NAME ' PHO E EXT, <br /> HOME or MAILING ADDRI�S FAX# <br /> llaa U� u v-e-- ( le) a 13-- � b <br /> CITY STATE 44 zip q <br /> BILLING ACKNOWLEDGEMENT: 1, 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 1 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: Iti � ��-i_t I,t i��-•Lt > DATE: 41 f©l QLC1 <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT p'W'h i ( . f 1 °/ v, <br /> IfAPPL/CANT is not the BILLING PARTY,proof of authorization to sign is required 14 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: PgyME <br /> tvj <br /> COMMENTS: —f7,'blr � <br /> 3 <br /> 2009 <br /> SAN '�QUI <br /> �, <br /> NDN H�p n,17-AL <br /> ACCEPTED BY: EMPLOYEE#: —`7d — <br /> DATE: <br /> ASSIGNED TO: EMPLOYEE#: Z DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: t I Y PIE: <br /> Fee Amount: ✓' Amount Paid 3 Payment Date l� V3 <br /> Payment Type L/ Invoice# Check# v 2� Received By: WZ31— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />