Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CL�3�v S'fJT✓�i/�`7 C�✓/�fI L 3f'"/�/�.''®0 5 <br /> OWNER 18AL� CHECK BILLING ADDRESS® <br /> .4-jl/ �117�Qt.//ltJ LO'u•tJi y—/�'Gl.�'l�C'w!�'•e1 .�E��—S'JZ/l' `,� <br /> FACILITY NAME /�gy p � /fin ` ten_ / ��g,.,�/%�,L7✓ /��//��C�/G� <br /> SITE ADDRESS 5'-? 7 / <br /> Street Number Direction Street Name city Zi Cade <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY �-,-., / STATE C d ZIP <br /> PHONE#i V E APN# LAND USE APPLICATION# <br /> ('120) S 3 O O /O <br /> PHONE#1 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR <br /> !^' CHECK If BILLING ADDRESS El <br /> BUSINESS NAME3 <br /> �. i <br /> 'ald PHONE 6� EXT, j <br /> FIeM"r MAILING ADDRESSFAX <br /> ® S o G (")a9) �t1 p ?e) 7 e <br /> CITY ��(��/Pdh� a STATE 0'4 ZIP --�9,5"2- / <br /> I <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 3. <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FE RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: �e 77 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign Is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property located at the I <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 /> 1 <br /> TYPE OF SERVICE�(/RREQUESTED: /� <br /> COMMENTS: IU Ill RCR1*1/I /�"'^7X v/e l CG//✓e2- <br /> /-2//.9/07 — `'ed p��t� I <br /> ACCEPTED BY: JZrGZ0-��' `y EMPLOYEE#: �.g rl/ DATE: IIAA 7 i <br /> ASSIGNED TO: `�, �`�,�Gav� EMPLOYEE#: (eldg 19 DATE: <br /> Date Service Completed (if already completed): 1112-119 -7 SERVICE CODE: P/E: f <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> s <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> i <br />