Laserfiche WebLink
f SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# _ :SERVICE REQUEST# <br /> 23b52 �/C/, <br /> OWNERf OPERATOR <br /> ( Fr L� CHECK If BILLING ADDRESS <br /> G yt <br /> OFF <br /> A ZNaaoe aw p5W-5 K� AP-5 . <br /> SITE ADDRESS4/q' 1�(' Toc <br /> Street Number D r�on r E f -Street!Jhma city �' �v ZIp Code <br /> {HOME or MAILING ADDRESS (If Di Brent from Site Address) ''/fp�'/''n�l� <br /> 1 IL f N Street Number L L Straet1Nf.e <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# % -f <br /> 969 1 i-f O 5 O <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR n ( LPv LV f r� <br /> K- t CHECK If BILLING ADDRESS <br /> BUSINESS NAME. f,A �JA I j ,A A ) A ` O, 1 O � (: PHONbE q o 5 ExT. <br /> Ho orM el I G[_AIDDDDRES \ Ir-t J�� '�-1 WI M 14i. > FAX# <br /> lJ — ( ) <br /> CITY /_ STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 bus' Jantified on this form. <br /> 1 also certify that I have prepared t ' applihat the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand rd , S ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE; 034 -7110 <br /> ROPERTY I BUSINESS OWNER❑ T ANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not t RTY 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 atsame <br /> e time It is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: FIV <br /> COMMENTS: I <br /> s 7 2p <br /> H N�Qp�RTT�COUNO <br /> MFNT <br /> ACCEPTED BY: ' /I i A I/'� EMPLOYEE#: 220 I DATE: 17 <br /> ASSIGNED TO: lil/T V� EMPLOYEE#: w DATE: vf /gr3 7 <br /> Date Service Completed (if already completed): SERVICE CODE: pit; /6e-331 <br /> Fee Amount:(11 U Amount Paid/7)G�� b Payment Date �� 7 <br /> Payment Type �SInvoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />