Laserfiche WebLink
SAN JOAQUIN COUNTY ENviRoNMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />1AOCI11TY_ ID I� <br />v IJ V,I `1 <br />HOME Or MAILING ADDRESS <br />� SERV1Cc REDUEST # <br />W D D <br />OWNER OPERATOR wLt v bv <br />aha <br />CHECK if BILLING ADDRESS <br />FACILITY NAME ,P t Tr <br />o�.a <br />SITE ADDRESSS N!ber <br />Lion <br />l� ill 11,1 IStlreVet lNeme I/1 <br />V <br />cityL✓ <br />Cotle <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE#1 EITAT <br />DATE: <br />APN # <br />LAND USEAPPLICAMON # <br />PHONE#Z rxT. <br />(2 ) 2q-- vtl <br />EMPLOYEE M <br />BOS DISTRICT <br />LOCATON CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS E] <br />BUSINESS NAME <br />PHONE# EXT. <br />HOME Or MAILING ADDRESS <br />FAX # <br />CIN 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 ENviRoNNicENrAL HEALTH DEPART.mENT hourly charges associated with this project <br />or activity will be billed to roe or my business as identified on this form. <br />I also certify that I have prepared this application and that the wort to be performed will be done un accordance with all SAN JoAQumT <br />CouNTY Ordinance Codes. Standards. STATE EDF: Ai.*rl <br />441 <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BCSL%TSS OWNER OPZT0a / MANAGER ❑ OTHER AtTTHORIZED AGENT ❑ <br />IfAPPuc4:vr is riot theB=GPARTr 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 ENvTRONMENTAL HEALTH DEPARTmENr as soon as it is available and at the same time it is <br />provided to me or my representative. OA <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />�o <br />MAY � 6 <br />3 N'194Q(ri �Q?2 <br />�to)FpgRq�NTY <br />ACCEPTED BY: <br />EMPLOYEE #: <br />D <br />DATE: <br />ASSIGNED TO: a, <br />EMPLOYEE M <br />�„S <br />DATE: <br />Date $eNICe Completed (If already completed): <br />SERVICE CODE: DW I <br />P / E: I U2 <br />Fee Amount: ✓ 2 <br />Amount Paid <br />/ b� <br />Payment Date <br />Payment Type OL4 <br />nvoice # <br />Check # Lcf 7� <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />