Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST P R b ) 4P ® d <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5+a�b�ckts k;os zz� o sROO 26 11 <br /> OWNER/OPERATOR <br /> t�Gw i nG CHECK If BILLING ADDRESS <br /> FACILITY NAME 1' I <br /> 5tacb,c.k's if\s�de �euA. '� 210? <br /> SITEADDRESS015'207 <br /> 6445 Street Number Direction Pac\ Str�l!Moe �^ Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SVaet Number Street Name <br /> CITY STATE ZIP <br /> PHONE 111 EXT' APN# LAND USE APPLICATION# <br /> ('Dq ) 412 - B600 <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CIAbtl : ,+ej'Nell Q3p5 C matl- <br /> TI(h01 LI ei ' 7 CHECK If BILLING ADDRE55O <br /> BUSINESS NAME t t�l'1 \ PHONE# En. <br /> �i lei 1 hi Ix 19 k3ocro4cs - I E514 <br /> HOME or MAILING ADDRESS FAx# <br /> -43&1 C*60%An. ;A" <br /> CITY Coal <br /> `_a' STATE C,,A ZIP '15414 <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 <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 licatioLandthatthe workto be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard , STATE anL laws. <br /> APPLICANT'S SIGNATURE: DATE: $•13 •Zo <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT.9 <br /> /fAPPL/CANT 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 <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: Plan RCV+•P.W <br /> COMMENTS: <br /> 1 <br /> S4 At4 QLII/v <br /> NF4 THDo <br /> E/cy gUrory <br /> ACCEPTED BY: - EMPLOYEEM DATE: <br /> W <br /> ASSIGNED TO: EMPLOYEE#: '(_ DATE: <br /> C [/V <br /> Date Service Completed (if already completed): 46 SERVICE CODE: 5 - PIE: <br /> Fee Amount: �' Amount Pai SI Payment Date zD <br /> �I <br /> Payment Type C!L Invoice# Check# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> I REVISED 11/17/2003 I <br /> r <br /> 1 ` <br />