Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT=,., <br />SERVICE REQUEST i <br />Type of Business or Property <br />>rzm; T e ra rrr <br />FACILITY ID # 1 <br />SN 653 <br />SERVICE REQUEST 11 <br />�sRb08 <br />OWNER/ 16PERATOR <br />Ie)n3 <br />PHONED EXT, <br />CHECI<1(BILUNG ADDRESS <br />FACILITY NAME L�.., „ 771�/.��� <br />l/{JB <br />�� <br />STATE zip <br />SITE DRE34� <br />V Street Ne ber <br />0, <br />DI c <br />"''Slre.N <br />��7/(�j� /�C/r y , <br />'�' ' 'C 'V <br />%��'J/�/� <br />HOME or MAILING ADD inDifferent from Site Ad ress)14�5 <br />Z'50�0 ZA <br />Slmet Number <br />�x/, <br />r y= <br />Street Namo <br />zoo <br />CITY , / <br />STATE ZIP Al/ 36U' <br />PHONEBt EKT <br />APN /i <br />ASSIGNED TO: <br />LAND USE APPLICATIONN <br />PHONE#2 EstBOS <br />EMPLOYEE 11: <br />DATE; <br />Date Service Completed <br />(if al eady completed): <br />DISTRICT <br />LOCATION CODE <br />CONTRACTOR /SERVICE REQUESTOR <br />REQUESTOR <br />BILLING ACKNOWLEDGEMENT: I, the undersigned properly or business owner, operator or authorized <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONED EXT, <br />HOME Or MAILING ADDRESS <br />FA%D <br />CITY <br />STATE zip <br />agent of same, <br />acknowledge unit oil site and/m• project specific ENVIRONMEN"I'AL HEACrH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />1 also certify that I have prepared this application and Chet the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Cortes, Slan(Ir7PCIS', <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/DUSINL'SS OIYNER❑ O LtAT'OR/A'I.INAGER OTHER AUTHORIZED AGe,N•r❑tca!y �J <br />Iffl PPL/CdA'T is 770 a UttttA�c Po7nrr, prod 'of nntlroriznifon to sign is regnb'erl Thh, <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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/o' environmental/site assessment <br />information t0 rile SAN IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the Same time it is <br />la'ovided to tine or my representative. <br />TYPE OF SERVICE REQUESTED: (:579K <br />EHD 48 <br />5 <br />Ars <br />Gl <br />COMMENTS; <br />ACCEPTED BY: <br />EMPLOYEES: <br />DATE: 113- <br />ASSIGNED TO: <br />v, <br />,-,�. 2.,. <br />EMPLOYEE 11: <br />DATE; <br />Date Service Completed <br />(if al eady completed): <br />SERVICE CGDE: 0 t <br />( <br />P / E: ` o <br />11 <br />Fee Amount: <br />Amount Paid <br />/j(p ?,�( <br />Payment Date <br />Payment Type �� <br />Invoice # <br />�j� �5 7 <br />Received By: <br />-02.025 SR FORM (Gordon Rod) <br />REVISED 11/1712003 <br />