Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST P/� 6) ((p D 7 7 <br /> Type of Business or Property � FACILITY IDR LS7 <br /> VICE REQUEST#� <br /> OWNER/OPE TOR '(?) //_/J <br /> Liu 0 <br /> CHECK if BILLING ADDRESS <br /> (A <br /> FACILITY NAME <br /> !q �. [�/1 Ap / t_ <br /> SITE ADDRESS PGLIOYL �-I/ILFVvl1 �5 <br /> 7! Street Number Direction street Nam. CI ZIP Coda <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t Eu. APN# LAND USE APPLICATION# <br /> PHONER Eu. BOS DISTRICTLOCATION CODE <br /> (22N ) P - 523 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> S CHECK it BILLING ADDRESS <br /> BUSINESS NAMES, 1 PHONE# V Ezr. <br /> 121 �1 O <br /> HOME Or MAILING ADDRESS FAX# <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 /> APPLICANT'S SIGNATURE: T DATE: 8�p2��o2U,Q� <br /> PROPERTY/BUSINESS OWNER PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLLCANT 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 af.[}Ale same time it is <br /> provided to me or my representative. 4 <br /> TYPE OF SERVICE REQUESTED: y <br /> COMMENTS: <br /> H f�Ro UI,V OUN <br /> ?F <br /> FACTyQF � <br /> OF otm , <br /> est 1 � w <br /> ACCEPTED EMPLOYEE#: 6'Zdo/ � <br /> ( 3 DATE: vW 7 <br /> ASSIGNED TO: '� EMPLOYEE#: /_ DATE: O' -/_ 4') <br /> Date Service Completed (if already completed): SERVICE CODE: ('_ I P E: K.Jr O <br /> Fee Amount: + .0 Amount Paid I a r' Payment Date �(2-(491 <br /> � 2lO' <br /> A 71P l i f <br /> Payment Type Invoice# [Received Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />