Laserfiche WebLink
SAN JOAQUIN _ jUNTY ENVIRONMENTAL HEALTH DEI .-RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST R <br /> 007Z°13� <br /> OWNER/OPERATOF>, <br /> l CHECK if BILLING ADDRESS <br /> FACILITY NAME }� ,( <br /> SITE ADDRESS 1 v' —r <br /> SoZ 7�" -St P.e� i6a i1 CA 1 _ i <br /> 54eet Numb¢r' �4DUeellon�-Y ¢ _ <br /> ,HOME Or MAILING ADDRESS(If Difteien�tr m.51teAddress) - <br /> _ <br /> CITY ---Q "-"'T�' •', `" "�'AS 'r'RE" .,!.x __—TA <br /> PeONE$1 WWII _ __ _— _— l.Ai! _._"_ . <br /> r _- OUSE�APPLICATION# <br /> ( ©0- ?-G . <br /> PHONE 62'--- —_. <br /> BOS.DISTRICT 'LOCATION CODE <br /> ( )aqd _ 9 2 <br /> T G <br /> CONTRACTOR/ SERVICE_ REQUESTOR <br /> REQUESTOR _n._ <br /> CHECK if BILLING ADDRESS O <br /> BUSINESS NAME "D_ PHONE 9 Err-- <br /> M <br /> rr. . <br /> _ M r rr -a 2 <br /> HOME Or MAILING ADDRESS -- "' -- " -- FA%¢' T <br /> weu <br /> CITY .—__ "— _ �__ _. _ _—STATE .— T ZIP <br /> BI CU N G ACKNOWLEDGEMENT: I, the undersigned property or business owner, .operator or authorized agent of same, ' <br /> acknowledge that all s@e.and/br'prb)ect specific ENVIRONMENTAL HE�Lnk DEPARngENT hourly charges_ associated with this project or j <br /> activity will be billed to me or my business as identified on this forrm. - <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 l/a�ws i <br /> APPLICANTS SIGNATURE: / DATE[ /r_ <br /> ( <br /> PROPERTY/BUSINESS,OWNER� OPERATOR/MANAGER ❑ OTHE_RAUTHORREO AGENT ❑ l <br /> 'If APPLICANT IS not the BILLING PART' proof Of aUtf101lZatiOn to S%gq iBregUlred �. Title _ "y <br /> f AUTHORIZATION TO RELEASE INFORMATION; When applicable, I, the owner or operator of the property loraled at the above <br /> site address, hereby authonze the.release of any and all results,,geotechnical data and/or environmentaUsite assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon as it is available and at the same time It IS provided f0 me Of <br /> ! my representative. <br /> TYPE OF SERVICE REQUESTED: ,/ .j .�.+s�IAGtA : - - - - -- " <br /> COMMENTS: / <br /> SAEC 004 C-fAL TM SA ENVIROMIE NTA LNC <br /> .H OEPARTMF-W HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: - <br /> AssIGNEDTO: �. '�rAmountPaid <br /> EMPLOYEE - DATE; / <br /> Ll <br /> Date Service Completed (if already compleSERVICE CODE: �/ PIS: <br /> Fee Amount: O no f 3 C p J Payment Date <br /> Payment Type C-- no <br /> # Z( / <br /> /_ Check# l O 3 S Received By: <br /> EHD 48-02-025 <br /> 07/17/08 SR FORM(Golden Rod) <br />