Laserfiche WebLink
5t- <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Res 4- S `� <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> o�YS r o <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 5 io�KTanl 9sao� <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) la-g—4 k p��fy/,r{R/F_ L,4�(,I l 54/rte. <br /> Street Nuumber Street Name <br /> CITY ��DCr_�O� $TATE�A ZIP Sao <br /> PHONE#1 E' . APN LAND USE APPLICATION t/ <br /> _061 ) �° (- I°l l -035-- 90 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION QPDE <br /> (-o ) 476 -coll 2 1 QAr <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> OA [/////� r� CHECK If BILLING ADDRESS <br /> BUSINESS NAME 'rG PHONE' <br /> �' <br /> ao 9� �l��a <br /> HOMEOr AILING A RESS Q ( FAX# <br /> • a I I ( ) <br /> CITY L-V6f— <br /> / STATE /� ZIP c� <br /> BILLING ACKNOWLEDGEMENT: 1, 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 certity that I have prepared thiAappra and tha le work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordi,rance Codes,Standen dd FED-R aws. ,�/� <br /> APPLICANT'S SIGNATURE: L�Gc`'%ZG�Y DATE: y 2 <br /> PROPERTY/BUSINESSOR'NER❑ OPERA'T'OR/MANAGER ❑ AFHERALITHORIZEDAGENTID <br /> If APPLICANT is not the BILLING PARTY',proof of authorization to si;n 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 io me or my representative. <br /> TYPE OF SERVICE REQUESTED: S ,A6e 5a B A9A1MeV1A1AUU <br /> n„ <br /> COMMENTS: <br /> ZC�1 <br /> IU/V <br /> _ SAM /JO 20,1 <br /> y'LT�I OJV cOUN, <br /> ACCEPTED BY: I EMPLOYEE#: DATE: �R( 2 <br /> ASSIGNED TO: \/� C' EMPLOYEE#: S DATE: 2-02 <br /> Date Service Completed (if already completed): SERVICE CODE: ✓�� PIE: <br /> Fee Amount: Amount Paid Payment Date 1 '2— <br /> Payment Type D Invoice# Check# 3` r� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />