Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property _ FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME (/ ! `J <br /> yc' 04 1A <br /> SITE ADDRESS Ll [ S 3 3 �Oi l C 1 � ( '� ,a ' (y� ,J�y cS <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( Zo ) tj <br /> PHONE #2 J n [' EXT. BOS DISTRICT LOCATION CODE <br /> ( 70Z ) 11 <br /> G J <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> v CHECK if BILLING ADDRESS <br /> Glo <br /> BUSINESS NAME �5 �) ( � Q �� �� (�/ C� �r PHONE # 7 � hl� '06 ExT' <br /> HOME Or MAILING ADDRESS ( ( J FAX # <br /> $ x( 41 ►ref Ave ( ) <br /> CITY f C ^ " e 0v02 STATE CA <br /> ZIP 9S ,? o S <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 andy*E9EKTTWS , <br /> APPLICANT ' S SIGNATURE : DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERAT W MANAGER ❑ OTHER AUTHORIZED AGENT J h s L, /, j, <br /> If APPLICANT 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 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. PA <br /> TYPE OF SERVICE REQUESTED : V &e^ l0. S Y e. r ) to 6K ) J ' I 5 W 1 M ' 'I Poo ) PAL,�I lo <br /> COMMENTS : <br /> D roo � Ir ojer.5' cam ! ► 1 - k 5't �t 11� +o l f CSL" y EW !A �iN C. <br /> 4 ? <br /> 61 � /J a ✓1f � tkJI S .jgs t.W) 1 ( �� ✓e �C Eatry0 ZZ 7444 rr <br /> IJ � fi © �v Ir, >n Ira' . cel ; 1 � ta ) )� 6 r <br /> ACCEPTED BY : v - S L � EMPLOYEE # : DATE : Z2Z- <br /> ASSIGNED TO : EMPLOYEE # : DATE: <br /> Date Service Completed (if already completed ) : SERVICE CODE : P / E <br /> Fee Amount: t�;o vl Amount Pal 3, Payment Date ZI ZZ c� <br /> Payment Type Invoice # Check # / b Recei ed By : <br /> EHD 4&02-025 SR FORM (Golden Rod ) <br /> REVISED 11 / 17/2003 <br />