Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> P` tF-F 512 00 69 02-3 9 <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> a u P 01? a PZ <br /> FACILITY NAME <br /> iY/aF o P Co o ,yta Zc� Lam <br /> SITE ADDRESS df yl <br /> 3 6o 6 /0 ,J creel Nummber Direction Street Name Zi Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> O e Street Number Street Name <br /> CITY STATE ZIP <br /> fOC D al e2 S /S <br /> PHONE#I EXT' APN# LAND USE APPLICATION# <br /> (209 ) o 6 1 0 `F- / 9 3 -/3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 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 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: /7 IIX'2 P/ (Zoll 7 C-c L P Z DATE: 'J- �� Z 0 <br /> PROPERTY/BUSINESS OWNER 11 T OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Time <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 t0 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. n <br /> TYPE OF SERVICE REQUESTED: {� O 0 �/ �.�I I CL�. CC i-i-C, G l O/J <br /> COMMENTS: CTAQ-/ Ia IJ.G .S TO Qi�� A_Tc�a �r� - —LCL! <br /> Yu�NT <br /> N0 co <br /> AE�FC-- JUN 16 2010 <br /> SAN JOAQUIN ETM <br /> M� <br /> ACCEPTED BY: �l V D.� EMPLOYEE#: O S, 2_r DATE:-1 /�'/0 <br /> ASSIGNED TO: £� "�T EMPLOYEE#: /_ 7�3 DATE: (�/l0 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: (003 <br /> Fee Amount: 0 /(S Cr-D Amount Paid l t'' f Payment Date 6/ 16/ 10 <br /> Payment Type C+ rl S Invoice# Check# Received By: m Gd <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />