Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />�, }) 0 i^ s t_ / U Vs >< {' &I <br />FACILITY ID # <br />BUSINESS NAME <br />SERVICE REQUEST # <br />` <br />OWNER/ OPERATOR <br />e r I c T` C V-') � ((-c'—'S <br />U <br />�1 <br />\ r <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />CITY L <br />ST E ZIP <br />TE ADDRESS ' <br />1L <br />St be Number Direction <br />/ <br />lam,- I <br />treet <br />Name <br />DATE: (7,/3 0 ' Z <br />Date Service Completed (if already completed): �_`-2-Z <br />SERVICE CODE: O ` <br />� �J <br />}/C ode <br />HOME AILING ADDRE If Different from Site Address) <br />Street Number <br />Amount Paid r `Sa. _ <br />Street Name <br />CIT <br />G 3 C"/ 2— <br />STATE ZIP <br />PHONE #1 � ^ XT� <br /># l S <br />APN # <br />� � <br />� <br />LAND USE APPLICATION # <br />PONE# /� (� <br />BOS DISTRICT[� <br />CATION CODE <br />Fr3 C4 <br />CONTRACTOR / SERVICE REQUESTOR I <br />REQUE OR u r/' <br />/ <br />�, }) 0 i^ s t_ / U Vs >< {' &I <br />1 <br />V 1,st (� CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />tirt I r��,s <br />1)LiS Coit F I� Gi +n J[ dt <br />}-o �t)( P C11Ti1?GN <br />PHONE # EXT, <br />HOME Qr MA G DDR /r <br />L_ <br />FAX# <br />CITY L <br />ST E ZIP <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 licati n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Sta dara �_ LIWA <br />APPLICANT'S SiGNATU �- DATE: NT <br />PROPERTY / BUSINESS OWNE OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ RECE II /ED <br />If APPLIC NT is not the BILLING PARTY, proof of authorization to sign is required Title G <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property l0JW & V2022 <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 thc$NI6M ;lINiCOUNTY <br />provided to me or my representative. <br />ENVIRONMENTAL <br />H FAITH DE TMENT <br />TYPE OF SERVICE REQUESTED: Ve (I lclt <br />�, }) 0 i^ s t_ / U Vs >< {' &I <br />•wt i "J t P 0 r } <br />COMMENTS:Tt'f iMt4- ,S Rpo1Ci! -L04 <br />1 <br />Cl• 512a3)C1$li� Si'r'le l <br />tirt I r��,s <br />1)LiS Coit F I� Gi +n J[ dt <br />}-o �t)( P C11Ti1?GN <br />n a� 1f�L t <br />vF S�,pi ,� ��,► I<-,�� <br />i CALL(209)95 <br />/. FOR INSPECI <br />24-HOUR N( <br />REQUIRES <br />ACCEPTED BY: Z_ Z_ <br />EMPLOYEE#: <br />DATE: G?;) 51.Z <br />ASSIGNED TO: ,/► S <br />EMPLOYEE #: <br />DATE: (7,/3 0 ' Z <br />Date Service Completed (if already completed): �_`-2-Z <br />SERVICE CODE: O ` <br />PIE: <br />Fee Amount: 57 <br />Amount Paid r `Sa. _ <br />Payment Date <br />G 3 C"/ 2— <br />Payment Type vi CJ <br />Invoice # <br /># l S <br />�� Yj U C Z <br />Received By: r' <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />3-7697 <br />-ION. <br />)TICE <br />