Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />HOME Or MAILING ADDRESS <br />SERVICE REQU T # <br />S�lX?i��t01 <br />OWNER I OPERATOR <br />�\Lc&r1Ar+�� <br />o <br />C)Soy\a Fon y-ee' <br />CHECK If BILLING ADDRESS <br />FACILITY NAME -I-71 /• Oc' gA <br />G i c ro <br />SITE ADDRESS ( at um Number <br />Street Number <br />Direction <br />/l j a� L ,v ^ A . o <br />l� l 7wStree`[ Name Tt"�- <br />CI <br />O" SZ� <br />2i Cotle <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />i -I Ll 0 Street Number <br />Amount Paid <br />r y V• (A V C' <br />Street Name <br />CITY � V}OV) <br />F- <br />Payment Type Ca-,.( <br />STATE zip ci -5 n <br />PHONE#1 EZT• <br />APN# <br />LAND USE APPLICATION# <br />PHONE#2 Em <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# Exr. <br />( r <br />HOME Or MAILING ADDRESS <br />FAX# <br />CITY STATE zip <br />BILLING ACKNOWLEDGEMENT: 1:, 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, S/anda S, TATE and F E laws. <br />APPLICANT'S SIGNATURE. � �SJ� �J DATE: PAYMENT <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZEDAGENI KtCEIVED <br />If APPLICANT iS not the BILLING PARTY proof of authorization to sign is required ' " O i, 'n�� <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property locate Rhe <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or envHonflAl'ht1QAftIh6Qu 7Nq* <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available a� 4F <br />*PLis <br />provided to me or my representative. L EPARTMENT <br />TYPE OF SERVICE REQUESTED: f66G• <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: owl <br />P / y ILI 0 2> <br />Fee Amount: It. P ew <br />Amount Paid <br />S l- <br />Payment Date 2 Z <br />Payment Type Ca-,.( <br />Invoice# <br />Check# <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/77/2003 <br />