Laserfiche WebLink
SAN JOAQUln'�f COUNTY ENVIRONMENTAL HEALTH APARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> _ _ 1 fJ� C✓KOb7�gZso <br /> OVIINER/OPERATOR -- — <br /> CHECK if BILLING ADDRESS <br /> �nyD EN1�'�P�ISES � <br /> � FACILITY NAME –A— <br /> r-7 JQ E I-AJ a co v�rLy <br /> SITE ADDRESS <br /> o SS ff�l17/ %aAx.y <br /> Street Number Direction Street Name etn, :...-ode I <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> V• / � 7 Street Number Y <br /> Street Name <br /> CITY STATE ZIP <br /> 9(/s s <br /> �PHONF#1 EXT. APN# LAND USE APPLICATION# <br /> (moo) C - 212- /60 - /o <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> 110 qo 27-3 30_- G so <br /> 'CONTRA-C T OR/ SERVICE PEQUESTO - - <br /> REQUESTOR <br /> L`I N A A UGLu to i c C CHECK if BILLING ADDRESS0 <br /> BUSINESS NAME 2 PHONE# EXT. <br /> HOME or MAILING ADDRE� Fax# <br /> e. Dy ( ) r L4 1 L 0 LLrtoO <br /> L'.et) <br /> CITY STATE zip Cp� <br /> �oY� c JOO <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 that e work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE 1 ,, <br /> APPLICANT'S SIGNATURE: DATE: �Y <br /> PROPERTY/BUSINESS OWNER 5a 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, 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 t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: ��� �� _� 24A; a� <br /> COMMENTS: <br /> �Fp?0 foe <br /> H Fhio�Q� �0/O <br /> Ro <br /> AV <br /> �'oeR,�' 'My <br /> ACCEPTED BY: 1f\ EMPLOYEE#: ��U� DATE: <br /> ASSIGNED TO: M Ck S EMPLOYEE#: Ctf DATE: ho ZQ I <br /> Date Service Completed (if already completed): SERVICE CODE: 7 PIE: <br /> Fee Amount:— Z7 �—Amount P �7T60 Payment Date 712-41)14v <br /> Payment Type Invoice## L Check# bl Race ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />