Laserfiche WebLink
w <br /> SAN JOAQUT UNTY ENVIRONMENTAL HEALTH,*ARTMENT <br /> SERVICE REQUEST <br /> Type of BU iness or Property FACILITY ID# SERVICE REQUEST# <br /> A4 BU <br /> 56r •e d T S KOO V5�03Y <br /> OWNER/OPERATOR I VE® <br /> CHECK H BILLING ADDRESS❑ <br /> FACILITY NAME AUG 30 2012 <br /> SITE ADDRESS ��r / r <br /> Street Number Directi ! S Na a ENVIR®NMT2i code 7 <br /> HOME or MAILING ADDRESS (If Different from Site Address) �.A04er PERI,I FWRVICES <br /> Street Street Name <br /> CITYJ S 7JP <br /> PHONE#1 ` EXT• APN# LAND USE APPLICATION# <br /> (No 3 r7 tF -o-9is I " /�( r,-, <br /> PHONE R EXT. ElOt DISTRICT LOCA N CCODE <br /> 75 <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR .-„--Q <br /> Tie <br /> CHECK H BILLING ADDRESS❑ <br /> BUSINESS NAME ✓ PHONE# EXT. <br /> run -� <br /> HOME Or MAILING ADDRESS ) FAX# <br /> - V--0-- 0 I ( ) <br /> CITYly STATE zip Z .7e <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 and FEDE aws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> !fAPPLICANT 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. 1 <br /> TYPE OF SERVICE REQUESTED: �{CAVV f'-f\ r�-A c&o pi <br /> 1 <br /> COMMENTS: , t <br /> L 1 m I PA v O�u,rT,R, r ca ns;zr ��>~�i(v. C exc cC(�J if C I�`�� 14 1 un+1 rs <br /> AUG 31 '.1,12 <br /> sAH ac <br /> E11Vi <br /> HLALTt- <br /> ACCEPTED BY: EMPLOYEE#: �W�� DATE: g 31 hL <br /> ASSIGNED TO: ' k nr �s Z b EMPLOYEE M 2� DATE: VII/It <br /> Date Service Completed (H already completed): SERVICE CODE: 5 'Z. P,E: IA4014 <br /> Fee Amount: ��� Amount Paid '*ate v'0 Payment Date ?73(/l Z <br /> Payment Type Invoice# Check# 2 [�3� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />