Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or roperty :::FACILITY ID# SERVICE REQUEST# <br /> row SIC s2 <br /> OWNER/OPERATOR " <br /> CHECK if BILLING ADDRESS LJ <br /> FACILITY NAME <br /> SITE ADDRESS S7 3 ' /`/{�'_'y/{�l. <br /> street Number- Direction `1 `� srnt N me it e,", <br /> HOME Or MAILING ADDRE S (If DiffereAddress) <br /> o o Kae 't Tom Site V StrentNumber ��Q�L. , NT ✓ , <br /> CITY tT4 ' ZIP ^ r2. O _/� <br /> C K � ✓l/ VI <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (Zaq) (Q'?&' poi <br /> PHoNE#2 EXT. Bos DISTRICT Ol Loo TION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �'� '�(v�C 1 S r f 1 CHECK if BILLING ADDRE55o <br /> BUSINESS NAME E , ^w^ i r� C ( lJ PHONE# ` 2-2— <br /> Ho <br /> IEXT. <br /> HOME Or MAILING ADDRESS ^'744\E- /� m _ FAX# (o <br /> (/ 1 ILS' �i/LZ� ( I <br /> CITY C STATE ZIP 0 <br /> SZ <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 the work to be p ormed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL ILO h% <br /> laws. <br /> APPLICANT'S SIGNATURE: t�,tc� CYl DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER E3THER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PART v proof of authorization to sign is required 7hte <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located aOve <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessmen�t7 <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provi -- tt�1NT <br /> my representative. pll E! <br /> jANTYPE OF SERVICE REQUESTED: vt --c.` 9 ti;5 <br /> COMMENTS: b4- AQUIN T.l, <br /> bw�l` `L �lL �� QpV 3 HEA THpOMEN ALN <br /> AR MENT <br /> ue k 01" WLrSs� Ty ��vV f5 <br /> ACCEPTED BY: I _t r EMPLOYED DATE: ( /.• <br /> ASSIGNED TO: V EMPLOYEE#: DATE: _6 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount L Amount Paid , 3p Payment Date I ! 115 <br /> Payment Type Invoice# — Check# Received By: , <br /> EHD 48-02-075 <br /> 07/17/08 SR FORIA(Golden Rad) <br />