Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTS p <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> z 2 v SQ 00V7- .Z <br /> OWNER/OPERATOR J14Ic� 1 �A I �^,^ / <br /> �lvVyrytf fAl/ 11•it/\ CHECK if BILLING ADDRESS <br /> FACILITY NAME • S D3 C& (eiU4CJ <br /> SITE ADDRESS 97,9(0 ��VillI� A� qng <br /> Street Number Direction Street Name it Zi Cod <br /> HOME Or MAILING ADDRESS (If Different from Site Addre;s)�� „r / ` <br /> Street Number �I� eel Name <br /> CITY M adeW STATE 4, zip'19 p109 <br /> PHONE#1 �/�� Ezc APN# LAND USE APPLICATION# ' v <br /> PHONE#2 Em BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR j�� G. <br /> J V fit/ CHECK If BILLING ADORESSO <br /> BUSINESS NAME 'A�f,�jr T� A�l,� � p PHONE /7V—� E'lT <br /> HOME or MAILING ADDRESS�� ✓ FAz# ) f r/ qqq y <br /> CITY STATE 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 t0 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> X�N�� ' DATE: <br /> PROPERTY/BUSINESS OWNEROO OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANTis not the BILLINCPARTY proof of authorization to sign is required Title <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. <br /> TYPE OF SERVICE REQUESTED: Ne,/j Cr Z Ri �e <br /> COMMENTS: <br /> )6A� O <br /> �v'1 ouo3 20� <br /> NSC M/a)'w Tq�IY <br /> ��FNT <br /> ACCEPTED BY: COLV,(LA ZrL 6v EMPLOYEE#: DATE: 2 -3 <br /> ASSIGNED TO: L,vAVnV� EMPLOYEE#: DATE: <br /> Z-3 ' ZZ <br /> Date Service Completed (if already completed): SERVICE CODE: PIE; /(pOZ <br /> Fee Amount: (j y , � Amount Paid / Payment Date 2 L,312 <br /> Payment Type Invoice# 13 8 _9�?2(p 114 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 p-0t53151(o S <br />