Laserfiche WebLink
SAN JOA& COUNTY ENVIRONMENTAL HEALTI. DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK((BILLING ADDRESS <br /> FACILITY NAME✓� O - S ! O /// <br /> SITE ADDRESS ,/�J G UyfG� 5 + .yT� Lis <br /> Street Number Dlir/ect[on Street Name 'Civ / ZI Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Aydr cress) <br /> < ffila'/�� 0 �/ Street Number Street Name <br /> CITY �-// / TATE ZIP <br /> PHONE#1 /O ` ExT APN If C LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR�J �-z- <br /> CHECK If BILLING ADORES <br /> BUSINESS NAME PHONE If EKT. <br /> HOME Or MAIL GADDR S FAX# <br /> / l f7ili O ( I <br /> CITY h C STATE ZIP <br /> %iJ <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 TATE and EDLL <br /> labs. 7 <br /> APPLICANT'S SIGNATURE: � ,/ I�I DATE: S --7" J —/ <br /> PROPERTY I BUSINESS OWNER❑/ OPERATOR/MANAGER—Lf 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 t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: RECEIVED 2017 <br /> LIG# Z `�ll AUG,O 20i? <br /> JOAOUIN COUNTNTAL Y <br /> SANJOA% TMMj <br /> ENVIR [� <br /> ACCEPTED BY: EMPLOYEE#: DATE! X- 7-/7 <br /> ASSIGNED TO: P- <br /> �) -M <br /> Z-,' EMPLOYEE#: DATE: D - 7- 1-7 <br /> _ I / <br /> Date Service Completed (if already completed): SERVICECODE: PIE: OZ <br /> Fee Amount: 'Sade Amount Paid IS 7 <br /> Payment Type C' Invoice# Check# - Received By: <br /> J <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />