SR0084198 - Laserfiche WebLink

Home Browse Search

C4 /I a -F lea. Z4 Gtr, A cd�a�c� 4v- s n s p ec+jq, SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST 2 U q 95,3 " -76q Type of Business or Property 5 /0-✓l�T�, Z -- BUSINESS NAME FACILITY ID # HOME or MAILING ADDRESS SERVICE REQUEST # OPERATOR OPERAT 14 O /l_/� � W CHECK if BILLING ADDRESS FACILITY NAME DATE: Date Service Completed (if already completed): 317E A DRESSL�Q'v ( Street Number Direction ri Street Name i Amount Paid 15-2 L 'It uV Payment Type VL, -;,a,— r5.3G> v Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Received By: Street Name CITY STATE ZIP (HONE #; � �'�T• Y - 3 S6 APN # �j � I �O' � LAND USE APPLICATION # PHONE #2 EXT. 1� BOS DISTRICTT7� CATION CODE iLa I CONTRACTOR / SERVICE REQUESTOR REQUESTOR /� & CHECK if BILLING ADDRESS I/'1t BUSINESS NAME PHONE# EXT. HOME or MAILING ADDRESS FAX # CITY STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE:2 DATE: PROPERTY / BUSINESS OWNER `LJ OPERATOR/ MAN GER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title PAYMENT AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property RMEI V ED above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the satEOnT H 'N21provided to me or my representative. �JCCIi" �J TYPE OF SERVICE REQUESTED: ^ (� AN JOAQUIN CENVIRON MEN COMMENTS: LC 4 LTH DEPAR Z �Q. i h v �1'; COY111�( lar to , 0A X s-�I C,4fa� c � e / .�" ACCEPTED BY: /f"y1 ✓ , EMPLOYEE#: DATE: 9 F ff 1 ASSIGNED TO: Q �r EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: �c P / E: G Fee Amount: / Z Amount Paid 15-2 Payment Date G, f 2/4 Payment Type VL, -;,a,— I Invoice #c 1 Sl b b g 5 Received By: EHD 48-02-025 C REVISED 11/17/2003 SR FORM (Golden Rod) )UNTY TAL VENT [i_