Laserfiche WebLink
0 9 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (a,5fic 5"(- SRoo W75' <br /> OWNER/OPERATOR <br /> a,l-han P VL� CHECJCifBILLING ADDRISSSQ <br /> FACILITNAM Vd tyic J 6O l 5 Sec t- Cn f;e-r St c n <br /> SITE ADDRESS tJor. h C0./' d(lniolS't' 7 9 <br /> g0 Street Number irectlon � Street Name !! 4 19 Stogy joty <br /> vi ��� <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) $?0- !CD 1Asm+ 4 12-1-7,50 -4150-0100 <br /> PHONE#2 - EExT, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME e O1.5 J� PHONE EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 or <br /> activity will be billed to me or my business as Identified on this form, <br /> 1 also certify that I have prepared this app ication and that the work to be perfo in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stan rdsr E an RA laws. H r 9 <br /> 0 <br /> APPLICANT'S SIGNATURE: DATE: I- iq -7-1117 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY.proof of authorization to sign Is required Tale <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it i5 provided t0 me Or <br /> my representative, 2N <br /> TYPE OF SERVICE REQUESTED: e� C H <br /> COMMENTS: <br /> O <br /> H:0' "4, ?O�� <br /> Evr <br /> ACCEPTED BY: � EMPLOYEE#: OO b DATE, <br /> ASSIGNED TO: MCIA- EMPLOYEE#: dOC) DATE: '/31/2 , , <br /> Date Service Completed (if already completed): �1 SERVICE CODE: PIE: L4t O3 <br /> Fee Amount: �k 3q,bo Amount Pal v� Payment Date <br /> r <br /> Payment Type 1 Invoice# Check# 107�L R ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />