Laserfiche WebLink
/ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 00S�0 0I <br /> OWNER 1 OPERATOR C <br /> r-k"� '�,� CNECK If BILLING ADDRESS <br /> FACILITY NAME LOA", Cc C`JO ^J � <br /> SITE ADDRESS (001 F Ke*i2mot h ' .^ LO t (�SZ��LJ <br /> Street Number Direction Surat Name Vr ' CI Zi Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 4'� CTI D6r� Wst <br /> Street Number St eet Name <br /> CITY C,` STATE (2a_ ZIP <br /> RONE#1 Y CY JEM. APN# LAND USE APPLICATION# <br /> (f3o ) (35Z <br /> PHONE#2 Ev. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR S 2 <br /> J CHECK if BILLING ADDRESS <br /> BUSINESS NAME t GV�Jtt'�/� PHONE# Exr. <br /> HOME or MAILING ADDRESS 4FAIL# <br /> ecDq Gl,or'rca � ( 1 <br /> CITY E l �{jfYc t)IS fit,\\� STATE C,4— ZIP 9 r-16-Z.- <br /> BILLING <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",Me wo e p aimed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA F aws. / <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ '�OPERATO ;NAGE] ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING 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 enviroF�µ¢ site assessment <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available 0 a t }fine it IS <br /> provided to me or my representative. �ECEf <br /> TYPE OF SERVICE REQUESTED: �bod U <br /> COMMENTS: I (� <br /> O�IGI� 0 OWVu^rs1n-� ENVIRONMENTALTy <br /> EALTH DEpART7AL <br /> MENr <br /> ACCEPTED BY: m EMPLOYEE DATE: <br /> ASSIGNED TO: 0A EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: QVI PIE: <br /> Fee Amount: G V Amount Paid /S6,00 Payment Date <br /> Payment Type Invoice# Check# fag Received By: <br /> EHD 48-02-025 01` {I^'/ DN" SR FORM(Golden Rod) <br /> REVISED 1'1/17/2003 / <br /> T7--.5 �1'� v� /Y �/.7 w-1 <br /> A � <br /> 'Cli~ K Vo L4, Xo5ti5 LP3 <br />