Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />0 i 1 r C <br />BUSINESS NAME <br />CA a man <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER /OPERATOR p <br />CD 1 I0 -S <br />' /'` /.� <br />/qq�t (eq <br />/t 1 ei QJ�I O1 1R-2, CHECK If BILLING ADDRESSEJ <br />Vim. �/ <br />FACILITY NAME j O ! pn o\ To <br />�1 e r (� <br />SITE ADDRESS —730 <br />3 <br />Street Number <br />Olreetion <br />Cal fore o, Sfir,�Q�. <br />treat Name <br />S�'O CI 1�n <br />J l�ty <br />Ci <br />1' 5105 <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />BibStreet <br />Number <br />,� <br />}r' Te� Cess D✓) c 5' 1 rQ-Q+ <br />`� ✓ /[ Street Nama <br />CITY to C. k --)- on <br />I <br />n <br />EMPLOYEE #: <br />STATE La. zip (� -Z� <br />o <br />PHONE #1 ExT• <br />c5I0) 706-1961-0 <br />APN # <br />P I E:ee <br />LAND USE APPLICATION # <br />PHONER ExT• <br />TOPayment <br />(# <br />Date �� <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Car os A U V ` U���eZ CHECK if BILLING ADDRESS � <br />tJPHO <br />BUSINESS NAME <br />CA a man <br />E# E'R• <br />510 -)o -IP'2D <br />HOME or MAILING ADDRESS 18 E�1 <br />r 3(z+fe <br />FA%# <br />n sheet <br />( ) <br />/ <br />CITY � C STATE C 0. ZIP 0 ) S 206 <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 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: �Y 1QS J v f(93J01 Ji n G, Oy4e�Z DATE: <br />PROPERTY / BUSINESS OWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />IfAPPLICANT is not the BlLLlNG PARTY proof of authorization to sign is required <br />01 /20%2.vZZ <br />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 environmentaUsite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and asame time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: �--O O C� <br />p ` � <br />COMMENTS: <br />/f/ <br />10 <br />�✓ J <br />10?� <br />y Nt• QN/NCO <br />TN�F�Tr'IJ <br />ry <br />MFNT <br />ACCEPTED BY: �� —� <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: \ / <br />EMPLOYEE #: <br />DATE: <br />te Service Completed (if alreadycompleted): <br />SERVICE CODE: j�2S <br />P I E:ee <br />[D8Amount: —� <br />Amount Pa' <br />TOPayment <br />(# <br />Date �� <br />ayment Type <br />Invoice # <br />Check 13 D 1-2- <br />Receiv d By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />