Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />r Type of Business or Property <br />1 i 4- I 0 <br />FACILITY ID # SERVICE REQUEST # <br />OWNER I OPERATOR <br />CHECK if <br />6 2 kX C C k .1 0 .4.2.i t (-1- 2 BILLING ADDRE!: SS <br />_ <br />FACILITY NAME G R \,/ cck -1-e r A- 4-1\lii V-c' LI ik <br />SITE ADDRESS <br />(--- 1 Street Number - <br />1 . _ <br />I Direction <br />-Hi . 5' ' '-- • Street Name . <br />0 i.f T1,-) <br />t f City I Zi. Code <br />I c;(7,11, 7) <br />I ' <br />HOME or MAIL: G ADDRESS (If Different from Site Address) <br />14- C/ <br />' ' ? 9 7 Al P1 n c r\ f /---A v't Di Street Numl..,1s Street Name <br />Orr_ STAT,F ZIP , <br />(. A g S- 3 76 , <br />PHONE #1 EXT <br />'--, <br />AF-N# LAND USE APPLICATION # <br />r <br />PHONE #2 EXT. <br />( ) <br />BOB DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REOUESTOR , <br /> <br />6) ( 0 G)14/\(' 1 -., CHECK if BILLING ADDRESS 0 <br />BUSINESS NAME -.. <br />( al i.or <br />PHONE # <br />cog) <br />EXT. <br />Home or MAILING ADDR <br />2,2 <br />A7 <br />9 9 Ad/IAA/ 1 <br />FAX # <br />CITY <br />2-;.`;17 <br />STATE ( ),.... ZIP 1 3 3 7-L <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 ap lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar ST TE FEDERAL la <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER <br />DATE: <br />OPERATOR / MA GER 0 OTHER AUTHORIZED AGENT 0 <br />3 —J'— 7,6 <br />11 APPLICANT is not the BILLING PARTY proof of authorization to sign is required <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at th0ve <br />Aga 1 .e <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment infor1-4344 <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided rw A r <br />my representative. A. Ilk-0 <br />TYPE OF SERVICE REQUESTED: 'FPO! ValiOie Itisp6AleDA 2 sAN , <br />COMMENTS: <br />" DEN fi <br />ACCEPTED By: <br />\-YeA.' <br />EmPLOYEE #: DATE: V. L.4 1 I c,„ <br />ASSIGNED TO: le-Gt at ef;?---$1 vie L1c ky_fxe_9 EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): 3ERVICE CODE: 0 P t E: \k,e0t3 <br />Fee Amount: A 1 o - 0 0 Amount Paid /C5'(') 7., Payment Date <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)