Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> REQUEST# <br /> TYPe of Business or Property FACILITY ID# SERVICE <br /> OWNER OPERATOR CHECK ff BILLINN <br /> 11 <br /> �aL•12 lel 0b,C <br /> FACILITY NAME <br /> ou <br /> cic �iz-zd <br /> SITE ADORE fIl,OlS `�j <br /> �676-33(o�53, <br /> 3to <br /> Fqq- <br /> � kac� WsSter/ ✓6Number D eNa <br /> HOME or MAIUNG ADDRESS (U DNremnt from Sim Address) I Y7qI m CD)C-� <br /> Street Number <br /> Cm Lem STA LP <br /> PHONE#1 E". APN N LAND USE APPLICATION# J <br /> (C)m H%3 -� <br /> PHONE#P En. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR(a-'eL Via lICL CHECKit SIWNG ADD <br /> BUSINESS NAME/�n.✓'�� /�� 'Ja �PC k LI1) PH � � <br /> Ho or MAILING ADDRESS Y� V FAX# <br /> / 7 7 rr7 S TI-f c 1 <br /> CITY • STATE �-y ZJP <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 ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this applicati and a wor o be performed will be done in accordance with all Sew JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S and J <br /> APPLICANT'S SIGNATURE: DATE: to <br /> PROPERTY/BUSINESS OWNEk OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLLCANTT✓///Tis���notthe BmLu✓GPARTY proof ofauthorizadon to sign is required Title <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 environmentallsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available i' aI jhe same time it is <br /> provided to me or my representative. r f t YM <br /> TYPE OF SERVICE REQUESTED: VF,o <br /> COMMENTS; IVUV <br /> 4 20?1 <br /> RON <br /> 106 41�N74t <br /> ACCEPTED BY: EMPLOYEE M �]3 DATE: I 1 7 1 <br /> ASSIGNED TO: r L EMPLOYEE#: �/ DATE: �1 dl <br /> Date Service Completed (If already completed): SERVICECODE: ' / P)E• // <br /> Fee Amount: 52"O Amount Paid /sa ( � Payment Date �l,J �l�L <br /> Payment Type Invoice# Check# / g/ -/ <br /> p\ U Received By: <br /> "S EHD 48-02-025 <br /> REVISED 11117/200310 r% ���� SR FORM(Golden Rod) <br />