Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />REQUEST # <br />akA LES/DEN / L <br />PHONE# EXT. <br />C)> v1- /G 5,2 <br />HOME or MAILIN DDRESS <br />14 - <br />��SERVICE <br />�f�0 q� <br />OWNER/ OPERATOR <br />CITY U n L/)Gk—, <br />CHECK if BILLING ADDRESS <br />mR . b LA o oPV111,1 <br />FACILITY NAME <br />SITE ADDRESS /OA / <br />E <br />50 W rh{LAND <br />InA MTEC-A <br />qj-3 36. <br />Street Number <br />Direction <br />Street Name <br />C Ity <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) eq 3G�L�=A'21�ATC� <br />�2ErG� B�✓p <br />Street Number <br />Street Name <br />CITY / ''/1 Ar� <br />�J <br />S66 ZIP <br />/ <br />-j <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />00 )9 c <br />-070-0Z$ <br />PHONE #2 EXT. <br />BOS DISTRICTLO <br />CATION CO�DE <br />( ) <br />/ <br />C el? <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CA,::. <br />EJ/Y L <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />OL�5N—k7�GoN U Cn n/( <br />PHONE# EXT. <br />C)> v1- /G 5,2 <br />HOME or MAILIN DDRESS <br />14 - <br />FAX# <br />CITY U n L/)Gk—, <br />STATE (f ZIP S3 el <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 app ' tion and tl )e work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, S and FWEa ws. <br />APPLICANT'S SIGNATURE: DATE: / 02 <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER❑lorization <br />HERAUTHORIZEDAGENT <br />If APPL/CANT is not the BILLING PARTY, proof of aut 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 environment I/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at "!*g e it is <br />provided to me or my representative. pp.-,__ NT <br />TYPE OF SERVICE REQUESTED: 1",A <br />COMMENTS: PI C, 0 Check <br />:he1 r <br />-• 1rt ! 4 2�2 <br />2 <br />ly, Q?oNMF ouNn, <br />H DEPS MINT <br />ACCEPTED BY: 1 Z' EMPLOYEE#: DATE: <br />ASSIGNED TO: / EMPLOYEE #: DATE: ' q1.2 .2 <br />Date Service Completed (if already completed): SERVICE CODE: 3 P 1 E: LI 01 1 <br />Fee Amount:3Ji I Amount Paid �U Payment Date 3 <br />Payment Type, Invoice # Check # 387.E Receive By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />