Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0000 9S 0 51�2bl'c')13N-2- <br /> OWNER/OPERATOR r CHECKIf BILLING ADDRESS❑ <br /> 6a10 P2t" .4 <br /> FACILITY NAME <br /> SITE ADDRESS /- [- f' 3 <br /> /5/ 5,- n/ tZ sf✓�G q ]J 6 <br /> Scree[Number pirecticn Street Name Cit Zi Cude <br /> HOME or MAILING ADDRESS (If Different from Site Address) I /,�O ne-cdp p� dJ/e� <br /> Street Number Street Name <br /> CITY /_ STATE C,6^ ZIP <br /> PHONE#I E APN# LAND USE APPLILICATION# <br /> (20f) 825- 26 S -4 <br /> PHONE#2 Em BOS DISTRICT LOCATON CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR /YL (ma/J y(le <br /> �j CHECK If BILLING ADDRESS <br /> BUSINESS NAME <br /> [� o4 A/\//�6 —�[ PHONE# Ems. <br /> C/�/( <br /> ( AM 2y <br /> 6 <br /> HOME Or MAILING ADDRESS / FAX <br /> i o GCaGt/JdeC/ PL ( ) <br /> CITY .moi_ /_ STATE Cw /1 ZIP " <br /> BILLING(/ACKN!/Of ACKNOWLEDGEMENT: I, the undersigned property or business owner, oppfe'rlator 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 I 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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IfAPPL/CANT is not the BILLING PART➢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 <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 /> I <br /> provided to me or my representative. e7kn u Lu—v 2 &�-ke 1 <br /> TYPE OF SERVICE REQUESTED: A y <br /> COMMENTS: d2� p_ _ ) <br /> ilk <br /> 84 IV J0 <br /> HE,q�TH oU/CDUNI'y <br /> Di�pACCEPTED BY: EMPLOYEE M. DATE: V1. , �l <br /> ASSIGNED TO: >� EMPLOYEE#: DATE: �v <br /> Date Service Completed (If already Completed): SERVICE CODE: '00 PIE: ((007— <br /> Fee <br /> 0V7— <br /> Fee Amount: (;-2_ Amount PaidHCl .Payment Date <br /> Payment Type V; _ Invoice# Check# / Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 \ fv it,24w ��J <br />