Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST PR DI 0033? <br />Type of Business or Property <br />BUSINEssN E <br />D T -OS U fZ OS <br />FACILITY ID # <br />SERVICE REQUEST # <br />Cts Wd _ <br />2 ___ ti- N <br />FA 9 <br />CITY STATE /'' ZIP O <br />ch-ro AJc14 <br />�r ix OSS�p <br />OWNER I OPERATOR <br />DATE: P� <br />✓ <br />ASSIGNED TO: <br />m <br />O GCHECK <br />If BILLING ADDRESS <br />FACILITY NAME / I� <br />, <br />— <br />°15-7 41M I <br />SITE ADDRESS ��, <br />l <br />�L/ �� C� <br />Payment Date <br />"1 5-7 i. <br />Payment Type <br />trees Number <br />Direction <br />S eot Name <br />Receiv d By: <br />Q <br />ZI CWod� <br />HOME or MAILING ADDRESS (If Different from Site Address),/( <br />L /vLV <br />/� Street Number <br />Street Name <br />CITYR C L� T -O / r <br />�! /V <br />$TAT <br />U <br />PHONE#I FXT. <br />APN# <br />LAND USE APPLICATION fr <br />( e - l zli2o <br />PHON #2 <br />29S -72 <br />BOS DISTRICT <br />LOCATION CODE <br />( <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />t JAQ co //i/L / I%-0 CHECK If BILLING ADDRESS <br />(/ Y� tic (' <br />BUSINEssN E <br />D T -OS U fZ OS <br />PHONE# ExT. <br />2 7 2 c7 <br />HOME or MAILING ADDRESS <br />FAX <br />2 ___ ti- N <br />( ) <br />CITY STATE /'' ZIP O <br />ch-ro AJc14 <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 />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, ETa CEDE laws. <br />APPLICANT'S SIGNATURE: DATE: D_!0 ,,9' <br />PROPERTY / BUSINESS OWNER w/OPERATOR I 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 />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time it Is prox $d to me or <br />my representative. _ A VA. <br />TYPE OF SERVICE REQUESTED: V� <br />n <br />y <br />COMMENTS: <br />A/ �8It <br />H HDepq�roou'v'ry <br />Wllvr <br />ACCEPTED BY: lr— S , <br />J <br />EMPLOYEE #: <br />DATE: P� <br />✓ <br />ASSIGNED TO: <br />EMPLOYEE <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />Amount Pa sZ z)e,12 <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Receiv d By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />