Laserfiche WebLink
i <br /> a <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT IZI <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SV_ O��ZG1 2 0 <br /> OWNER/OPERATOR <br /> n CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS (` l� �1 ��� leo 1 J>�Z��L)C- 'f <br /> 34�t ►. <br /> • Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE \I <br /> ( S G <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRES <br /> BUSINESS NAME PHONE# EXT. <br /> cb- O� <br /> HOME Or MAILING ADDRESS �V^ CQ FAX# <br /> CITY t(7 .� G�{y STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENT, HEALTII DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identif d on t ' form. P <br /> I also certify that I have prepared this applic ork to be performed will be done in accordance with } Vi T <br /> COUNTY Ordinance Codes,Standards E a ERA S. '` �IV <br /> APPLICANT'S SIGNATURE: DATE: <br /> y 20 <br /> PROPERTY/BUSINESS OWNER[] OPERATOR/MANAGER 13OTHER AUTHORIZED AGENT rI.SP "-'�'luilit_aE"a <br /> If APPLICANT is not the BILLLVG PARTY,proof of authorization to sign is required Ti[t RO UNTY <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the pr ti 3hlc8$1?�tr NT <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: C O n S fA cl I Q <br /> COMMENTS: LO G�T`rte eQ° I G C eA G D fZ—14'0- I <br /> jzOUT <br /> c 7A-C i o p o f-q-4 54 2 £xp o csJ TA,%/ c.�A- <br /> !o �yaiD or tZU M <br /> ACCEPTED BY: ,5 $ r/ 1 EMPLOYEE#: DATE: <br /> ASSIGNED TO: el n K U L1 EMPLOYEE#: DATE: '2 <br /> Date Service Completed (If already completed): t IQ.9SERVICE CODE: 6) 6 I p/ <br /> E: /a 212 <br /> Fee Amount: K, Amount Paid i s Payment Date (� <br /> Payment Type I Invoice# Check# 22ZI V Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />