Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />FI?UIT ST +OV D <br />q i" A (%OV I <br />OD I <br />S�Z Q09S5 SSS <br />OWNER I OPERATOR <br />o C-t2MAt <br />R- <br />dAMD� <br />CITY U (; I:A SD K\ <br />CHECK if BILLING ACJDD"3RES3S <br />FACILITY NAME RAmcns CIo-I,VTi\ /� NE 2 <br />SITE ADDRESS <br />�((/� <br />qL <br />H AL )Y7NpFENT <br />MAA/r-C� <br />I <br />5� <br />✓ Street Number <br />Dlracllon <br />vACh/T`Nme <br />Street <br />�- <br />Cit <br />21 Coda <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />EMPLOYEE #: <br />g <br />DATE: <br />Date Service Complete (if already completed): <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE#1 E'tr• <br />APN # <br />Payment Type (/ <br />Invoice # <br />LAND USE APPLICATION # <br />(2 -q75) <br />Received By: <br />PHONE Ew. <br />('oto) to S- IV 91 (O7 <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />O -f ! M ((O �L r, ^ b <br />1 •� <br />CHECK if BILLING AGGRESS <br />BUSINESL.S-NAME <br />N M O C Cbr \.A A\ -r R ` <br />(2-b Z �E � <br />PHONE # EXT* <br />HOME Or MAILING ADDRESS <br />FAX# <br />o C-t2MAt <br />R- <br />( ) <br />CITY U (; I:A SD K\ <br />STATE ClY ZIP 9C5 3 <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. ( �1 <br />APPLICANT'S SIGNATURE: �^C DATE: I <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br />JfAPPLtCANTis not the BILLING PAR TP 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 environmentaUsite 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. <br />w_ <br />TYPE OF SERVICE REQUESTED: <br />AGI C�r�Vlsua'V"�ivs�. <br />•.f <br />COMMENTS: <br />e- (i -n <br />(ii/ /o ! - / ,kl <br />AN <br />t//[1 <br />� 3 <br />$qA✓ 2Q?2 <br />KQU <br />H AL )Y7NpFENT <br />` <br />ACCEPTED BY: <br />EMPLOYEE d' <br />�- <br />DATE: (e_2 2-2 <br />V' J G._ <br />ASSIGNED TO: e <br />r <br />EMPLOYEE #: <br />g <br />DATE: <br />Date Service Complete (if already completed): <br />SERVICE CODE: <br />P/E: W� <br />Fee Amount: I C32 _ <br />Amount Palq45LS2, <br />Payment Date <br />3 �z Z <br />Payment Type (/ <br />Invoice # <br />Check # //$� <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />