Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Typ f Busipess or Property FACILITY ID# SERVICE REQUEST# <br /> It JCkC 0 S DO <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME 110r`C n f `I / <br /> o P0 rl <br /> SITE ADDRESS J f ` 54d .AC o n �zb <br /> Street Number Direction Street Name CII_ I ZI Cotle <br /> HOME or MAILING AD ESSIf ifferent fro Site Ajddress) <br /> LLA Street Number Street Name <br /> CITY S r& zip CA if CG <br /> PHONE#1 Eu. APN# LAND USE APPLICATION# <br /> (;M) 0- 61 2v <br /> PHONE#2 Ezr. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEL II Q ( e PHONE 6 -612-,-, . <br /> HOME Or MAILING ADDRESS FAx# V <br /> CITY I ��. ST EO f ZIP 7 /� <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 /> 1 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. <br /> APPLICANT'S SIGNATURE: nII'rJ t f,, nt o Pd ek DATE: <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER ❑ OTHERAUTHORIZEDAGENT❑ <br /> 1�'APPLICANT iS not the BILLING PARTY proof of authorization to sign is required Title <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/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available ame time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: V Q Y 1 1 �`l,Q y ' ( r I, Vv civEp <br /> COMMM,ENTS: �/7 7 20 <br /> �fper'NT <br /> y&fZW 7y <br /> At <br /> 9-830 rtr� p <br /> ACCEPTED BY: ��t �j EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �` P 1 E: ; 3 <br /> Fee Amount: Amount Paid 41S w Payment Date 22- <br /> Payment Type lL<15L_ Invoice# Check# Recelved By: <br /> EHD /I / � /I 6� SR FORM(Golden Rod) <br /> REVISEDSED 1 <br /> 11/1/1 7/2003 (/�7Jdn(i/' <br />