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SAN JOAGtT11N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR r I r f�ll <br /> CC: L• �CN1/ CAI—Ilai2�uv'� CHECK If BILLING ADDRESS <br /> FACILITY NAME ��-C- <br /> RM� I L_A15 txl catJ <br /> SITE ADDRESS l 9 S-.QrC'r-L 1 cN/ 95-,�-(�� <br /> Street Number Direction �T Street Name C,tv Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Sheet Number Street Name <br /> CITY STATE ZIP <br /> STC �=-rGaJ Ca � Sin <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (ICCT 15 -9 3 0 <br /> PHONE#2EZT. BOB DISTRICT LOCATION CODE <br /> ) I !!�`9 J i <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If81LLINGAODRESS <br /> BUSINESS NAME ` PHONE# Ext <br /> HOME or MAILING ADDRESS FAx# <br /> P , 0 <br /> CITY C�r�C^V--Tr,-I STATEC/�' ZIP 11 <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 foam <br /> I also certify that I have prepared taacation and th a work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standardnd FEDL laws. <br /> APPLICANT'S SIGNATURE: DATE: -7J <br /> PROPERTY/BUSINESS OWNER 0 ATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT iS of the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon a5 It IS available and at the Same time It Is provided t0 me Or <br /> my representative. y� <br /> TYPE OF SERVICE REQUESTED: U ati(A ti <br /> COMMENTS: <br /> EN AQUI <br /> ./Y NFAIT I p NMENTUN <br /> ACCEPTEDBY: ��, } EMPLOYEE#: DATE: , I FNT <br /> ASSIGNED TO: U Y 'VA+ EMPLOYEE#: DATE: 1 <br /> Date Service Completed (if already completed): SERVICE CODE: 014 PIE: <br /> Fee Amount: 15 G V Amount Paid /0a O� Payment Date ((/`1/ <br /> Payment Type (�a�� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />