Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S RVI E REQUEST# <br /> '50g0�5 <br /> OWNER/OPERATOR <br /> -�1 CHECK It BILLING ADDRESS <br /> $ 10 e c-le — <br /> FACILITY NAME <br /> 40 C—-z-- <br /> SITE <br /> SITE ADDRESS ES 0!� 9 S Z <br /> Street Number Olraetlon Street Name C ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Numb Slreet Nama <br /> _ <br /> CITY \ , 6e(DYCILI,-1 STATE CIq ZIP O <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> CZ07) 6 7a zi / 3 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR -fr-���` <br /> 0 ��-- e US 'I ��Z �/✓e � CHECK if BILLING ADDRESS <br /> BUSINESS NAMEI-(] C ,Z `1 1�t�� PHONE#) 6 TQ Z+ ( E'IT <br /> HOME Or MAILING ADDRESS . <br /> 2 `�,�/� e � 7I II) C' � <br /> CITY <br /> FAx <br /> # ) <br /> � "i'UC -�(0 I STATE / 9 ZIP s ? o <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, STAT and FED WS. I <br /> APPLICANT'S SIGNATURE: _4 a^__ DATE: /Cis�� ��� <br /> PROPERTY/BUSINESS OWNER❑ OPERAT ANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT i.Y not the BILLING PARTY proofofauthorization 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. <br /> TYPE OF SERVICE REQUESTED: Z P <br /> COMMENTS: a NT <br /> IVOV Q�iVFD <br /> SAN'10 X020 <br /> I� M4TH110%,C NNry <br /> ACCEPTED BY: t}y, EMPLOYEE#: DATE: 1/�r <br /> ASSIGNEDTO: V 1l/c. EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: h o^ Amount P ' / U Payment Date 3 ZD <br /> Payment Type Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />