Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST Piz 01 (0(-) 3q B <br /> Type of Business or Property a FACILITY—IID# SERVICE REQUEST# <br /> ?d&avraw-1 <br /> OWNER/OPERATOR <br /> Env; t.e to/- <br /> CHECK if BILLING ADDRESS E] <br /> ' <br /> FACILITY NAME <br /> UGv4-i7 —1--Cc)S <br /> SITE ADDRESS 2-) 3 / aUw C1Jdj ry�� 5 • �� �y?O r/ <br /> Street Number Direction L/ StreetlName S7 Cit 7ZiJ Cotle7 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY SFtla/U' STATE C'4'n ZIP <br /> 7 <br /> PHONE#1 Ex. APN# LAND USE APPLICATION# <br /> (ZEel ) 6 pC/ r�i?70 <br /> PHONE#2 Ex . BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> L.a- <br /> 7P <br /> (pvPS CHECK It BILLING ADDRESS <br /> BUSINESS NAME '' PHONE# EXT. <br /> ( 905) <br /> HOME Or MAILING ADDRESS a� FAX# <br /> CITY ` STATE 6,,f ZIP 'T'5'Z J Jj <br /> J .Z <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 mysmess as identified on this form. <br /> I also certify that I have prepared Ih's I plication and that le w k to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standas STATE and FEDE L law .. <br /> APPLICANT'S SIGNATURREE: DATE: 0{g/oc, Z 1 <br /> PROPERTY/BUSINESS OWNERd PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPe/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 environmental/site assessment <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tl 1nle time it is <br /> provided to me or my representative. Ny <br /> TYPE OF SERVICE REQUESTED: eye. <br /> COMMENTS: AUG <br /> � ja �osdebirrleni <br /> Pia2r4a4 � �nat' /. co � • l C7 �62021 <br /> SAN JOAQUIN <br /> hPANTHIROlv COUNTY <br /> 1)PAR M NT <br /> ACCEPTED BY: l.•/— EMPLOYEE#: DATE: <br /> AssIGNEDTO: ', ` EMPLOYEE DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O 1 ,� P I E: 1 <br /> KIL <br /> o <br /> Fee Amount: \��J Amount Paid /s�e Payment Date <br /> Payment <br /> �6 <br /> Payment TypeInvoice# Check# �a�"p/s -��� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />