Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />L Wb� (,tom (�� \t bUN& <br />�� -A <br />_b o 2Z. <br />;W0%9o-? <br />OWNER i OPERATOR <br />I � j . �-. �- -��` � C C if BILLINGADORESSC� <br />1 v�,�j�-- <br />�� �y % F 6,��� O <br />/k�k (1 <br />FACILITY NAME Ni) efrl A „U �y 9aN W ivV {� * <br />SA -t --I LTYYR i+r'7+J Q F1 LI.., <br />SiTEADDRESS <br />e. <br />*6Lrnte Ln • <br />SERVICE CODE: �6,23 <br />Llb <br />PIE: yVpa <br />Fee Amount: <br />Nam <br />Payment Date <br />t <br />f Cod <br />HOME or MAILING ADDRESS (it Different from Site Address) <br />10 C-• aZ <br />r- <br />a <br />" Street Number <br />_ <br />CITY S Tb r') <br />STa zip <br />PNDNE#1 E.. <br />(zoa)�ce�—%01�� <br />APN # <br />0( 5--too—b <br />LAND USE APPLICATION # <br />PNDNE#Z Exr• <br />BOS DISTRICT , / <br />LOCA7N�ODE <br />CONTRACTOR I SERVICE REOUESTOR <br />REQUESTOR n , 6 egrtI <br />r�' <br />CHECKIf BILLING ADDRESSL <br />BUSINESS NAME /t �, <br />� (�rt P � W GW L��, LLt• <br />� �.. <br />�# EXT. <br />HOME or MAILING ADDRESS <br />t 3 2s- USD <br />ACCEPTED BY: XIZAZ" .�1 <br />FAX # <br />(T:t V74 -- 19'2 -9 - <br />CITY \i 4Ouni <br />STATE OJ- zip '9 ",1 <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 we 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 />APPLICANT'S SIGNATURE: �-� DATE: <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER)4 OTHER AUTHORIZED AGENT ❑ Dtit tftK Q& <br />V'APPL1CINT 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 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 />TYPE OF SERVICE REQUESTED: /�l� ✓ ��/ <br />/�c�,o Y`� /7 G�/� Q.{ <br />;ta <br />Commms: <br />V <br />R FcF/ <br />AUG ? <br />su <br />flyy�gQUl;y C <br />ACCEPTED BY: XIZAZ" .�1 <br />EmpLOYEE #: ygf g-0 <br />DATE: // <br />ASSIGNED TO: /r/AI1 - z `�"C <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (H already completed): <br />SERVICE CODE: �6,23 <br />PIE: yVpa <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type / <br />invoice # <br />Chcok# 079 /� <br />Rece ved By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />ail <br />h'>y <br />