Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> 00 q0 ' <br /> OWNER / OPERATOR 1AJAt Cr.d CHECK if BILLING ADDRESsa❑ <br /> Nvl 6 r� �t� <br /> FACILITY NAME U P. S4'o `l ion <br /> SITE ADDRESS 01 N t?rvkdI i� 5� �, fon �f .5d0s" <br /> Street Number Dt o Fl St et Name City Zin Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number fes ' Street Name <br /> CITY ro i 4r ,M1d STATE f � ZIP ei f i <br /> PHONE #1 77� EXT• APN # LAND USEAPPLICATION # C Ot <br /> PHONE #2 ExTv BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR cf <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE # EXT• <br /> r d; 5 y$y 9iM2 � 6s3 <br /> HOME or MAILING ADDRESS 1 / FAX # <br /> CITY STATE9! ZIP © OL <br /> rVo +� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of some, <br /> acknowledge that all site and/or project specific ENwRoNm NTAL 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 Codes, Standards, STATEAnd FEDE laws , / <br /> APPLICANT'S SIGNATURE : DATE : f�/f / � � <br /> PROPERTY / BUSINESS OWNERM OPERATOR / MANAGER 13 OTHER AUTHORIZED AGENT G+sc, c•sle <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE YNFORMATTON : 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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative, PAYMENT <br /> TYPE OF SERVICE REQUESTED , SJt RECEIVED <br /> COMMENTS: � T J 2020 <br /> C CJSAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY : EMPLOYEE #: DATE: <br /> ASSIGNED TO: ( ,��J— �-�� / r� - EMPLOYEE #: DATE: AzN40 . <br /> Date Service Coompl�e`te already completed): SERVICE CODE: l� 11 PIE : 23 D9 <br /> Fee Amount: � ' C'w Amount Paid • rye Payment Date Z J <br /> Payment TypeC I,, ; �IInvoice # Check J4 117 q 3 0 9 Received By: <br /> i <br /> EHD 4M2-025 SR FORM (Golden Rod) <br /> REVISED 11/1712003 <br />