Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SR <br /> WNERI OPERATOR —, <br /> l av \ �`^ CHECK If BILLING ADDRESS <br /> FACILITY NAME 1 5 1 ' ms r ' <br /> 1 <br /> $-1TE,ADIn <br /> ,PYESS I i <br /> Street Number Direction I LjStmet Name Cil �21 cotle <br /> N E or MAILING ADDR SS (If Different from Site Address) 1 <br /> L( tredt Number Street Namecc, - <br /> CRY \k- STATE ZIP <br /> PHONE#1 Ez. APN# LAND USE APPLICATION At U <br /> 09 211 3 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST R <br /> C 4��� egcM o,Y\oi c k m r CHECK if BILLING ADDRESS <br /> BUSINESS NAMEu r'O G Shap <br /> PHONE# I 1 7 <br /> G <br /> MAILINGAD RE (Ax# ) - <br /> CIN C K <br /> STATE Q 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 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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> If APPLICAVT is not the BILLING PARTY 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 environmentaalllsiite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at ntet�ltate_time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �� <br /> COMMENTS: aaqgtr <br /> 3 1Q <br /> rk <br /> ACCEPTED BY: EMPLOYEE DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C)'Z-2j PIE: <br /> J I <br /> Fee Amount: f LI 5W, Amount Paid p Payment Date _:52,3 22 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />