Laserfiche WebLink
SAN .JOAQL... COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> : I Sfz0073gej <br /> OWN /O ERATOR <br /> ACHECK If BILLING ADDRESS <br /> FACILITY NA o i okJ 1\a Alcoa I in orl� <br /> Y. SITE ADDRESS <br /> G13JSKeE[Yumber ,-tion Street Name ��DEI( �� Zi✓Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) O G <br /> 'f eet Number / WAyme <br /> ly CITY STAT ZIP <br /> PHONE#1 LAND USE APPLICATION# <br /> l9 yO5-1/O 3 5 ExT. APN# <br /> PHONE#2 EKT. BIDS DISTRICT LOCATION CODE <br /> ® J 1 2 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 0/,J <br /> f CHECK If BILLING ADDRESS <br /> BUSINESS NAME 11 'vl p p P If ExT. <br /> 05- O 3 <br /> HOME or MAILING A DRESS FAX# <br /> 6 Wet t ) <br /> CIrr�T— l n - STATE ZIP .n q6 <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 Or <br /> 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Vn/a nttx RArogarl DATE: 10 -1q— <br /> PROPERTY/ <br /> 0 -! q—PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time it is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: I � .eM .e -h/. PAYMENT— <br /> COMMENTS: RE <br /> OCT 19 2015 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> _ HEALTH DEPARTMENT <br /> ACCEPTED BY: EM :?Dir_ <br /> PLOYEE#: DATE: to <br /> ASSIGNED TO: /J fl �!1_„ ��() n/1 EM PLOYEEM DATE: �1��n17� <br /> Date Service Completed (if already�completetl): $ERVICECODE: !LL PIE: I(,iz <br /> Fee Amount: 4130 d 3 U J Payment Date Cob5 //5� <br /> Payment Type C .S t,1 Invoice# Check# Received By: <br /> v �— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />