Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �P 002� t,0b5Q00 <9�0`8L'I <br /> OWNER/OPERATOR �,�yI <br /> yk l�l / CHECK If BILLING ADDRESS <br /> 120 <br /> FACILITY NAME V <br /> SITE ADDRESS <br /> Street Number Dlrectian Street Name CH Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> 7 V NI C <br /> PHONE#t / Exr• APN# LAND USE APPLICATION# <br /> PHONE#2 EXr. BOS DISTRICT LOCATION CODE <br /> I ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 7 t- MITI Lyn CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exi. <br /> HOME or MAILING ADDRESS FAX# <br /> Io iAa ( ) <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 IOAQuIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: /'A 'Ke" L?n DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> YAPPL/CANT 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 enviro ,�{L1��.y(.r�1{�e{/,s,iitte assessment <br /> information to the SAN IOAQUW COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available Sly/�It4Cle It is <br /> provided to me or my representative. C _I P <br /> TYPE OF SERVICE REQUESTED: LV\O�n 2 O JvJC\2.rS k-. <br /> COMMENTS: $AtvJOAQUI 1 <br /> Zlvv[RNC <br /> HST y Dz p';�N At <br /> M NT <br /> ACCEPTED BY: KL EMPLOYEE#: DATE: S l0 2I <br /> ASSIGNED TO: l��(1�0�r-e EMPLOYEE l.( S DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0 b I P/E. y b O 2 <br /> Fee Amount: 1 S Z— Amount Paid Payment Date Z <br /> Payment Type Invoice# JJJJ1111 r\ C 2 QG1 j�5 I t Receive By: <br /> REVISED 11EHD 017/2003 Y rU )J� D ! 3 SR FORM(Golden Rod) <br /> 1 <br />