Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r-7 S�r°b4�oL{93-4— <br /> OWNER/ <br /> 4—OWNER/OPERATOR <br /> CHECK It BILLING ADDRESS <br /> SIT <br /> FACILITY NAME ,, '/�-y�- <br /> SITEADDRESS l 1 LN C�fLl vN 95z.,,07 <br /> 5'?I StreelNumb¢r Direction �C �vti SlrlOtName �/ O Cil 2i Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Scree!Number Street Name <br /> CITY STATE ZIP <br /> P�HOO,N,E[#1 d EXT' APN# LAND USE APPLICATION# <br /> It 7's5o <br /> PHONE#2 E41, BOS DISTRICT LOCATION CODE <br /> �) —hl`13o Z p <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORti / 1S Cs ' ( ) <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONi# OEXT. <br /> 5 � 7e ` 24/q3 <br /> HOME Or M0LI�AD2SSL FAX# <br /> 7 C <br /> CITY f � <br /> STATE d zip <br /> BILLING ACKNOWLEDGEMENT: , the It dersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/ol' project Specific NVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my bu mess a identified on this form. <br /> I also certify that I Have prepared this 'call n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar nd FEDERAL laws. - Y <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT [•/j�} �J / \ <br /> IJAPPLICANT 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaVsite assessment <br /> inlbrmation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> pi o\ided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: eolI <br /> COMMENTS: <br /> ACCEPTED BY:ff O L iEMPLOYEE#: DATE:S /� �Z <br /> ASSIGNED TO: �EO�L>4 EMPLOYEE#: �3 DATE: •j[ i I <br /> Date Service Completed (if already completed): SERVICE CODE:5-•2.� P 1 E:� ( <br /> Fee Amount: 2$'p, Amount Paid �!_V Payment Date Z <br /> Payment Type Invoice# Check# (rL Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />