Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> s�av$2s►a- <br /> OWNER/OPERATOR <br /> L 7 �2Q`L w 2 <br /> CHECK I(BILLING ADDRESS <br /> Am <br /> FACILITY NAME l.J L.J <br /> p.s ZA0, R1 J'0 S A v <br /> SITE ADDRESS n W o?SS SYO OX-7a� 86272-. <br /> ��S�e Number i 11 cityZI Cotle <br /> HOME or MAILING ADDRESS (If Differe�Ilt f o Site Address) <br /> 1 , Street Number <br /> CITYC / STATE ZIP q <br /> PHONE#1 J �/ EXT. APN# LAND USE APPLICATION# `(f <br /> coy) 570 -0//3 1 - <br /> PHONE#2 EXT. BIDS DISTRICT LOCgTION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR _ <br /> o56 <br /> R CHECK If BILLING ADDRESS <br /> BUSINESS NAME / ,T PHONE# EXT. <br /> AW Idxkt7-w 7ft16os I-A'Jo< <br /> HOME or MAILING ADDRESS FAX# <br /> ti9os w 9 s" ( ) <br /> CITY 7,,,`p Kit <br /> N C STATE ZIP C5l <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 apply 'on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST4V FEDE �1(0 <br /> APPLICANT'S SIGNATURE: J DATE: ` <br /> r ` 210 <br /> PROPERTY/BUSINESSOWNER❑ OPERAT AGER ❑ OTHER AUTHORIZED AGENT El <br /> IfAPPL/CAUT is not the BILLING PA TY 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 ttime It is <br /> provided to me or my representative. IN 7- <br /> TYPE OF SERVICE REQUESTED: TiA , IVF <br /> COMMENTS: O �\ p ,„ '- , `� .ew. JO <br /> I�rJVIWU`�Vl�y _ qQ <br /> Zu O <br /> HFACTVIRC tf' o'V Ty <br /> N�FPgR M NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNEDTO: fA <br /> EMPLOYEE#: DATE: f� <br /> Date Service Completed (i(already completed): SERVICE CODE: PIE: <br /> Fee Amount:lk, 1C�2,_ Amount Paid 15,? 00 Payment Date 92 11 <br /> Payment Type Invoice# Check# #3/77t3 1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />