Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 50 OD-95°r4+ <br /> OWNER I OPERATOR / /' <br /> CHECK If BILLING ADDRESS 11 <br /> FACILITY NAME / <br /> SITE ADDRESS <br /> I /•u/� •�D C/ S/ OC ]7JI� /� - 03 <br /> 730 Street Number Direction C� Street Name T CI 7 ZipCode <br /> HOME or MAILING ADDRESS (I Different <br /> f om Site Address) <br /> ,1 /v( Street Number Street Name <br /> CITY STATE Cq ZIP l/S ZC--1S <br /> PHONE#1 Ex, APN# LAND USE APPLICATION# 7 <br /> (2Li) 2 9869 70 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR I ///'''ry _ �, <br /> K �C CHECK If BILLING ADDRESS <br /> BUSINESS NAME G,`y/[ r PHONE# Ext. <br /> HOME Or MAILING ADDRESS C {,A��` /�L\ )CCI-3 n ( # 1 <br /> CITY a C D 1 1/-� �1 -1 J •'1 STATE ZIP / Q <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 FE laws. <br /> APPLICANT'S SIGNATURE: BW7 DATE: I0/2— — Z Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> Of APPatCANT is not the BILLINGPARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the properDented at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmenta s n7�' <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at I eo*!1i�15 <br /> provided to me or my representative. _�C E� <br /> TYPE OF SERVICE REQUESTED: .e Z <br /> COMMENTS: E JOAQUINC H <br /> HEALTH DFpgR�NT <br /> ACCEPTED BY: EMPLOYEE M DATE: 'I� 2. Z Z <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Pa' Payment Date <br /> Payment Type Invoice# Check# !SZ I q�3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />