Laserfiche WebLink
SAN JOAQUIPCOUNTY ENVIRONMENTAL HEALTH EI PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> \ 0 C���e CHECK if BILLING ADDRESS <br /> FACILITY NAME J <br /> i�ckoar�C_OCA' SR" .n r q_ <br /> IT ADDRESS <br /> S0(� `e/'y << CC �-- 1(,.SC`- Ian 3C�✓�'(� <br /> ADDRESS <br /> 430 �tie�t NuM�r Direction `(tit r)5treet-Name i Zi\Cade <br /> HOME Orjhl�AO<ING, �S�(if Different from Site Address) <br /> JJ UU Street Number Street Name <br /> CITY an n STAT i ZIP 0 <br /> I ' � <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> b - 7Jc 72 IlpC'12 <br /> PHONE#Z r ' EXT. BOS DISTRICT LOCATION CODE <br /> 1 CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> S�N(? <br /> � CHECK if BILLING ADDRESSE] <br /> BUSINESS NAME L� �U PHONE# �D 8- ? EXT. <br /> u J <br /> HOME Or MAI GAD SS FAX# 93 <br /> CITY STATE zip (� ]a_0 <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 /> I also certify that I have prepared this application and th ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE nd FEDERA laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER L ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> If APPLICANT is not tI1 BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time it is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: 30d' fty!4 C'enSu°l-I-x*011 G PAYNENT <br /> COMMENTS: <br /> ICEIVED <br /> r EB <br /> 2 6 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 7 <br /> ASSIGNED TO: EMPLOYEE#: DATE: 2- <br /> Date Service Completed (if already completed): 3�5"/1� SERVICE CODE: PIE: <br /> Fee Amount: 5 ZOa Amount Paid152. cc_ Payment Date �-( �>$ <br /> Payment Typerl�rr�'t k Invoice# Check# �('CX5��I(, Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />