Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> EE <br /> CHECK If BILLING ADDRESS 63 <br /> FACILITY NAME h <br /> SITE ADDRESS / ' S r/ /ZOLI(� /j/ PO TQ�3�/� <br /> ` Street Number Direction Street Name /� Ci Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> P. 6) • 3 Street Number Street Name <br /> CITY lzf ro`/`t I STATE ZIP 2 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# J <br /> PV q60 -k304 1 C,)-I9-3-/00 - /-7 <br /> PHONE#2 EXT BOS DISTRICT 777 <br /> ATION CO E/ <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> ' n 1 t g_- CHECK if BILLING ADDRESS <br /> BUSINESS NAME (J „F PHONE ExT' <br /> � � m6 u� N� 40z- <br /> HOME or MAILING ADDRESS FAX# <br /> d 4- ( ) <br /> �-CITYSTATEI / nLOC /1 n ZIP G3 <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.Ht:;ALTii 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. d F ERAL laws. <br /> (9 APPLICANT'S SIGNATURE: DATE: b f <br /> PROPERTY/BGSINF.SS OWNER❑ PERATOR/M.ANAG OTHER AUTHORizED AGENT[3 <br /> IfAPPLK'AN'T is not the B11,1.I:\rG 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. p <br /> TYPE OF SERVICE REQUESTED: ` G EC O S. 5 0eC <br /> COMMENTS: <br /> JSAIV UN 16 ?020 <br /> 11Eq-rOROIyMr:tV-r 7 y <br /> H DEPARTMENT <br /> ACCEPTED BY: L� EMPLOYEE#: DATE: (-.//E 0,;C) <br /> ASSIGNED TO: EMPLOYEE#: DATE: apaO <br /> Date Service Completed (if already completed): SERVICE CODE: s a 3 P I E: q a o <br /> Fee Amount: 43o L Amount Paid Payment Date U2 I <br /> Payment Type Invoice# Check# L-'O Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />