Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />REQUESTED: <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />SERVICE REQUEST # <br />8Per,i bAvi To,> <br />HOME or MAILING ADDRESS <br />FAX # <br />Z2S1 'Dom t';LV� Sut - Ito <br />OWNER / OPERATOR <br />`J m' ^C AL! <br />e .., n <br />r pc M <br />` LC <br />1� <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />ZIP 9 F(O& / <br />SITE ADDRESS <br />c�Z5�r Street Number <br />E <br />Direction <br />M a iN�—�•T- <br />Street Name <br />�jTUGl�i7YJ <br />Cit <br />qS2 j <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from <br />2S <br />Site Address) <br />SUtT�17 �) Street Number <br />DDUcj(..A. S T3 LV D <br />Street Name <br />CITY <br />�osEv�t.{ <br />CA <br />STATE ZIP <br />95ft(O(a <br />PHONE #'I <br />ExT. <br />APN # <br />EMPLOYEE #: <br />LAND USE APPLICATION # pAw� `3.1L <br />(Zol) <br />I2S�—(too I -JPA�D-1oo <br />'-o(W943. J <br />PHONE #2 <br />( ) <br />ExT• <br />EMPLOYEE #: <br />DATE: <br />BOS DISTRICT <br />i <br />LOCATION CODE <br />CONTRACTOR /SERVICE REQUESTOR <br />REQUESTOR r T1 <br />BILLING ACKNOWLEDGEMENT: <br />REQUESTED: <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME( N J �Lt �NtA L LI✓ <br />PHONE# <br />Exr. <br />HOME or MAILING ADDRESS <br />FAX # <br />Z2S1 'Dom t';LV� Sut - Ito <br />( ) <br />FB �0 <br />CITY Cv� LL <br />STATE CA <br />ZIP 9 F(O& / <br />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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codec, StaHdards, STATE allcj FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />DATE: 7�6 ` ZeLZ- <br />PROPERTY/ BUSINESS O1YNBR❑ OPERA"['OR/1Y[ANA�EA L! OTHERAUT[[ORILGDAG[:N'I'� �J�C� �lC?�"hlt d�.�v�tJi�M��%� <br />IfAPPLILNT is ttof the BILLGVG PrlRI., proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: W <br />hcu 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 <br />NO <br />VE® <br />7p2� <br />o <br />ANT ) <br />144 IV <br />REQUESTED: <br />COrMENTS: <br />FB �0 <br />Sq N <br />JQq <br />NEA <br />ThRNMF <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: 2 <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already com eted): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: <br />09b — <br />Amount Pal 30 �� <br />Payment Date <br />1Z� <br />Payment Type <br />C <br />Invoice # <br />-7 /2 <br />Check # /2474 7.T <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />