Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST PR D 5 4&3 ;LL/ <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F400-?-&;2q <br /> OWNER/OPERATOR <br /> ,a Allcio I'_ ^ � -� CHECK If BILLING ADDRESS <br /> FACILITY NAME �(/` all <br /> lV' V �(f� <br /> SITE ADDRESS <br /> (ef Na <br /> a me NGIS <br /> Street Number Olrectlon reCil ZI Cotl'JJe <br /> HOMED MAILING AD`ESS (If ifferent from Site Address) A <br /> Iv Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (M ) 51 - ✓las <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR MAAlr -�4 A (cf.a _ <br /> n CHECK If BILLING ADDRESS <br /> BUSINESS NAME I � I U - //� PHO&# , n EXT. <br /> W` r C- <br /> HOME or MAILING ADORES / FAX# <br /> IY ( I <br /> CIN STATE ZIP <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 FED'ER�A�tlaws. <br /> APPLICANT'S SIGNATURE: </G��Y "?" —� DATE: la- Z 7 ZO 20 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT 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 i5 available and at the Same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: C&Sw1 <br /> COMMENTS: <br /> 0-11 <br /> Ni°/A 6 ?0 <br /> d�I � vC <br /> 4(Gfy�F�TOul >Y <br /> ACCEPTED BY: AMA EMPLOYEE#: O/l DATE: I <br /> ASSIGNED TO: EMPLOYEE#: � ( Q✓✓✓ DATE: <br /> Date Service Completed (if already completed): SERVICECODE: / I PIE: �03 <br /> Fee Amou Co Amount Paid �J a Payment Date 02Q12 0 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />