Laserfiche WebLink
4 <br /> SAN JOAQUIN' rOUNTY ENVIRONMENTAL HEALTV T)EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F.rn� o o« i�00, <br /> 30 <br /> OWNER/OPERATOR ral <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRE p-- 1 <br /> 1(S•l( I 1`� � (��J fi �-I r /1 Com- /'ZC'kZc� T l GiCJ 's-3014 I <br /> et Number Direction Street Name CZi Code <br /> HOME or MAILING ADDRE (If Different from Site Address) <br /> OZ /ry3 Jj. 5 r^✓✓�Z'� f�,A Street Number Street Name <br /> CITY STATE ZIP <br /> e-'i -M s3 <br /> PHONE#1 T. APN# "r-v? LAND USE LI ATIO <br /> PHONE#2 _ EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Fje, 1 �hei`ts cd vi <br /> BUSINESS NAMEPHONE# EXT. <br /> 5 l3�F �1 L i►�,i f�� � �rtv�c Shy � C:t� ,, �2v�i 1/Y / 39 � <br /> HOME or MAILINGADD ESS f FAX# <br /> CITYrr.';'�! STAT fi ZIP c%S 3 0 y <br /> BILLING A KNOWLEDGEMENT: 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 or <br /> 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: �a Yl / DATE: G OV! I(J <br /> c� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER)I OTHER AUTHORIZED AGENT❑ <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 envirotunental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the We time it is <br /> provided to me or my representative. M� ` <br /> TYPE OF SERVICE REQUESTED: E O <br /> COMMENTS: <br /> ulo <br /> SIN iiA Wk oevp' <br /> ACCEPTED BY: 1 EMPLO EE#: c z I DATE: L /03 <br /> ASSIGNED TO: —(zc EMPLOYEE#: L{S (, DATE: / �l <br /> Date Service Completed (if already Completed): SERVICE CODE: S P I E: ZC,t--� <br /> Fee Amount: A k 6, C O Amount Paid Payment Date <br /> Payment Type Invoice# -FC heck# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REViSED 11/17/2003 <br />