Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Propertyfa FACILITY ID# SERVICE REQU �$]'!/�# <br /> Sat �� B <br /> OWNER OPERATOR <br /> CHECK If BILLING ADDRESS <br /> r <br /> FACILITY NAME <br /> SITE ADDRESS U1I1 �U(Y11�1 CC G G y'fl �70 / S� <br /> } <br /> Street Nu r Direction Street Name Cit Me Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 141 <br /> 13 e- e— dg,( e- lr2 Street Number //ll of Street Name <br /> ffY STC - ZIP 1 <br /> v rC/ <br /> PHONE#t <br /> Err APN# LAND USE APPLICATION# <br /> 209 52'7`7 9- 7 <br /> PHONE#2 Ear• BOB DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> V f.,,./� CHECKIf BILLING ADDRESSO <br /> BUSINESS NAME C/ e r� 'r'V`V 7 �' P UryQ TNE Ear. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY —t U CK U k/ STATE <'PIL ZIP '— <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 wor o b erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL 1 . /7 �^ _ �7 <br /> APPLICANT'S SIGNATURE: J DATE: c/j 2 L <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tale <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 to me or my representative. A, <br /> TYPE OF SERVICE REQUESTED: 4tN6U cwwCie <br /> COMMENTS: A <br /> N f.*LIQ H/Nt,�O� <br /> ��Fa FNrq�>Y <br /> � FNT <br /> ACCEPTED BY: Vo EMPLOYEE#: DATE: a (u Z2 <br /> ASSIGNED TO! I. L�Vlo <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (n P IE: O <br /> Fee Amount: 4-1 1;2 _ Amount Paid /S2 ob Payment Date <br /> Payment Typ Invoice# Check# L63172'612 1 Rec Ived By: <br /> EHD A I SR FORM(Golden Rod) <br /> REVISEDSED 11/1 11!17/2003 � 1Y <br />