Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Drm Cre Ic of i,.lr Jlw-d 1✓Ic <br /> FACILITY N E <br /> I/ice/ <br /> SITE ADDRESSE S} L.f�'6"d 4 9T-2JS <br /> 10 Ce C Stmet Number Direction e±: vS} Street Name city_ Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street me <br /> CITY STATE ZIP <br /> PHONE#1 Eu. APN# LAND USE APPLICATION# <br /> 129 ) 367 — qz fo <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> ( 916 ) Ul(e — Zd ),r <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS❑ <br /> BUSINESSNA E PHONE# E'R' <br /> k c <br /> HOME rM/ULINGA DRESS FAX# <br /> 10 60 S{^4 t ( ) <br /> CITY7 !_� STA E ZIP 75-2'U <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 aws. <br /> APPLICANT'S SIGNATURE: _ DATE: <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ O'rHER AUTHORTZED AGENT❑ <br /> JfAPPLICANT is not the BILLLVG PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 JoAQuTN CouNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. PAY <br /> TYPE OF SERVICE REQUESTED: SEI V <br /> COMMENTS: <br /> UG 16 2011 <br /> SAN JOAQUI <br /> HEALTy D E M N7Y <br /> ACCEPTED BY: 1 EMPLOYEE#: DATE: <br /> ASSIGNED TO: I,.. r.'i o� EMPLOYEE DATE: <br /> Date Service Completed KKK(it already completed): SERVICECODE: T(�,/ P/E: -7,TIT- <br /> Fee <br /> Amount: /S; b'�o Amount Paid �� U Payment Date:E, 7 1 <br /> GI <br /> Payment Type Invoice# I Check# ,) -70 16 Received By: Z�- <br /> EHD 45-02-025 �O Il„b�/ A� SR FORM(Golden Rod) i <br /> REVISED 7 1/1 71200 3 <br />