Laserfiche WebLink
SAN JOAQUI' COUNTY ENVIRONMENTAL HEALT'-DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME=t4s I.�'1 e <br /> SITE ADDRESS <br /> -571<4P—i <br /> 'g.302. Sheet Number Direction Street Name J'57Cit Zip 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 /> ( ) <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUrE STo n ( <br /> `o5�m POO( O1L1,1/V ,S{-ea,p.l Mac. 1'&J� CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> ,-?�7dr Y9s- 99 x7 <br /> HOME or MAILING ADDRESS FAX# <br /> sdoo MoF5;NJ It ad va>> say_ �sy9 <br /> CITYCev s STATE..._ ZIP �3G� <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: f— y/(;a� DATE: t018110 <br /> PROPER /BLfiSII9ESSOWNER11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> A=1C=f APPLICANT is not the BILLINGPAR71'proof of authorization to sign is rewired Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above siI address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> informatton-ffthe SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT as soon as it is available and at the same time It is <br /> provid?drt5-ire or my representative. /� �� `/� ,�- <br /> TYPE OFSERVICE REQUESTED: -?OCD(_ S,0,J "-,d4 e- l� r�-[ l� L [. �� C H <br /> COMMENWTS% '— <br /> - Sq ✓UN 18 FO <br /> H N�gO //v 00 <br /> OF_M 9 1J <br /> ACCEPTED BY: DL EMPLOYEE#: DATE: <br /> Q�- f Q <br /> ASSIGNED TO: /// EMPLOYEE#: 63 DATE: <br /> fD <br /> Date Service Completed (if already completed): SER 22- PIE: <br /> Fee Amount: 230 - Amount Paid/�® "� PaymentS- <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 � 16a 7T47 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 / <br />