Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID It SERVICE REQUEST# <br /> s ; SH07?Y79 <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> A ! C/ <br /> CIUTa AME ulce S Ly -79 <br /> SITE ADDRESS <br /> C �o �kcWJ <br /> Street Number Direction �d;A Street Name S CiIt, ZI Cotle <br /> HOME Or AILING ADDRESS (If Different from Site Address) ���� )eet N <br /> Street Number Strame <br /> CITY O STATE ZIP <br /> S G )^ <br /> PHONE#1 E%T, APN# LAND USE APPLICATION# <br /> (169 60 6 1q OUZO <br /> PHONE#2 EXT. BOS DXIST�`T LOCATION C DE <br /> ( ) (JV C <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR <br /> ^^ Cr?GCfU CHECK If BILLING ADDRESS <br /> B�LSINE$S NAME Do/cc PHON(9 coEI EZT.v <br /> OMEor MA INGADDRESS FAX It <br /> �UYee� i�1 <br /> CITU V I O TATE ZIP y. 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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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: s`iI4(90 DATE: /.1 --// 20 /-;4 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I 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 infor jion <br /> l0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 Soon as It IS available and at the Same time It Is provided t�rA%Yy p, <br /> my representative. R '•��rY1• <br /> TYPE OF SERVICE REQUESTED: �® <br /> COMMENTS: L ,, / S�✓Oq ')0�� <br /> H47y FPgR 00117-1, <br /> fNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEEIII: DATE: <br /> Date Service Completed if already completed): / SERVICE CODE: U P/E: 1 <br /> Fee Amount: 1 5 Z D Amount Pam w� �� Payment Date 1(/ <br /> Payment Type ( ZInvoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />