Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH 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 - <br /> vcffi e <br /> SITE ADDRESS qhswSC�-Yl�t}E <br /> Street Number Dlrectlon Street Name A V z Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) LIV / Se on I_ Ln <br /> 2220 Street Number Street Name <br /> CITY t` STATE ZIP <br /> N CA GS3 `I <br /> PHONE#1 Err. APN# LAND USE APPLICATION it <br /> (ug ) �9W '2_!5'J2_ 20 Qf <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> (26'0 201 —1g3Z <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME e ' 1 PHONE# Ear. <br /> HOME or MAILING ADDRESS FAX# <br /> t ( ) <br /> CITY �- STATE ZIP <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 <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 FEDERAL laws. <br /> QpPPLICANT'S SIGNATURE: DATE: L-1 4312-1 <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorizatiott 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at me time it is <br /> provided to me or my representative. <br /> kae— <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: R 7� <br /> 40.4 tV CS, ouill <br /> Z� <br /> ACCEPTED BY: C\, "Onle i EMPLOYEE#: DATE: <br /> ASSIGNED TO: C� \` IC. li EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Qom\ <br /> Fee Amount: \GZ Amount Paid I✓J P Payment Date t <br /> t 1 <br /> Payment Type Invoice# 12 3g 22�25 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> ILI <br />