Laserfiche WebLink
6 � <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> %J 1 S �LCA--\ <br /> OWNER/OPERATOR CJ" AN`i) A REpp. \r 1� <br /> I l f � �(GIW 1 ,ITZ F� 1JOY CHECK if BILLING ADORES4O <br /> FACIurr NAME �'„tU CaFe <br /> SITE ADDRESS \15$ S T2Rp1-CION t'lcvNTAiAI No 9g y <br /> Num r it <br /> HOME Or MAILING ADDRESS (If Different from Site Address) :Z 1=. A N C'lE Ll N A A\) <br /> E <br /> Street Nvmber e <br /> Cm "0QiSTP'tJ Htousa ST�1TE� zip 953`l1 <br /> � <br /> ( l"e) —\31 04 <br /> 0 �APN* LAND USE APPLCATION# <br /> P <br /> f ONE#2 }35 En SOS DISTRICT LOCAMON CODE <br /> O15� <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT.. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> r'm STATE zip <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 certify that f 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 �Q— �/; ,,t iJd�L/f,.,()r IDATR: Q4 I]� tZ07� <br /> PROPERTY/BusmESSOWNERL`S OPERATOR/MANA R ❑ `SOrittERAUAUTHOR—IZED AGENT 13 <br /> ffAPPLICANT is not the BILLING PARTr proof of authorization to sign is required rine <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,dIc 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 eoviroumental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same tlm)py 5 <br /> provided to me or my representative. �� <br /> TYPE OF SERVICE REQUESTED: F�AOR VI�I T <br /> COMMENTS: �0 <br /> SgN./p •�!(/ <br /> H ENVigQtr/ <br /> ON q T-4 rn' <br /> ACCEPTED BY:Cl EMPLOYEE#: DATE: <br /> ASSIGNED TO: �, \ vo\/)a L EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: " P/E: <br /> Fee Amount: ��_Le Amount Pa' �/ l)D Payment Date 7 I <br /> Payment Type Invoice# Check# 127 O b Receive ey: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> Qfr owl �° <br />