Laserfiche WebLink
SAN JOAQUu't COUNTY ENVIRONMENTAL HEALTh liEPARTMENT <br /> SERVICE REQUEST <br /> Type of IBIusinesss or Property / FACILITY ID# C SERVICE REQUUEES�T}#2 <br /> -1 k J�Inoa( lkrtln (OX � 4� J 900 <br /> Ow /OPERA o J ( c S oo I IJ) f�, <br /> 73 (J CHECK If BILLING ADDRESS <br /> FACILITY NAME RI <br /> K <br /> SITE ADDRESS <br /> a C� <br /> Street Number Direction S aet Name Ci 2i Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) I 068- 00-4,10 <br /> PHONE#2 E%r• BOS DIST T LOCgTION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHO # Ex. <br /> e <br /> e iK a r i �G k 93 -(Gcx� ro <br /> HOME or MAILING ADDRESS \\ FAX# <br /> 5-o / muse- C1i <br /> CIT' \ / d ( I I STATE 6 zip <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE/ad FEDERAL la S. <br /> APPLICANT'S SIGNATURE: dOt2 (i7 t1��T1, DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 4a OTHER AUTHORIZED AGENT 13 <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 <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: G f•EE/4-C.'T}1 �(.,yl;.q/ <br /> COMMENTS: f \ <br /> �et�o 1� I1er VGC3� P'IR) t diG3n 3ra �es, RECEIVED <br /> AUG 11 2009 <br /> SAN JOAQUIN COU <br /> FN%nRONMENTAL <br /> ACCEPTED BY: OLC Ue((G,4 EMPLOYEE#: X12 DATE: M <br /> ASSIGNED TO: r n 4A '� .A EMPLOYEE#: W DATE: el(( A6 <br /> Date Service Completed (if already completed): SERVICE CODE: S Z PIE: k&6Z <br /> Fee Amount: `rs^D Amount Paid S Payment Date l,, 61 <br /> Payment TypeInvoice# Check# ` 1 2 \ \ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />