Laserfiche WebLink
SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />1 w <br />BUSINESS NAME 'id <br />ve <br />'A ( <br />SERVICE REQUEST # <br />5200 75'� 51V <br />OWNER/OPERATOR ZAkri1,,w,dJvd -0/�Gi -M,tJL% CHECK if BILLING ADDRESS❑ <br />FACILITY NAME Sg lJ // l is /t 1, ( % uO <br />..1 jJ /' (: [�E <br />^� dilL <br />SITE ADDRESS ) � 6.7 <br />Street Number <br />Direction <br />H LJ\f � <br />SVeet Name <br />r <br />%p GEI �Q� <br />CI <br />gsZ3 <br />ZI Cotle <br />HOME Or MAILING ADDRESS (If DifferenSjrom Site Address) <br />str¢ee Number <br />Street ame <br />CITY /' ^ <br />U <br />STATE <br />.1 <br />E.T. <br />PHONE#1 <br />( f)-— 6/� <br />APN# <br />� o�R37o�� <br />LAND USE APPLICATION ## <br />PHONE #2 EXT• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVI E REQUESTOR <br />REQUESTOR 1t1e�_I��I <br />�' 0`�I <br />{rAtl I CHECK if BILLING ADDRESSM <br />JNN%✓ <br />BUSINESS NAME 'id <br />ve <br />'A ( <br />COMMENTS: <br />PHONE EXT' <br />/ / <br />J O <br />HOME or MAILING ADDRESS <br />^� dilL <br />SAX# ) <br />CITYA <br />STATE /' A ZIP j�/ %Z <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 Or <br />activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this a P#6ation and tat the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standa ATE and FE <br />APPLICANT'S SIGNATURE: DATE: d <br />PROPERTY/BUSINESS OWNER OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT Is not the BILLING PARTY, proof of authorization to Sign IS required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the spAYMEt Ipvided to me or <br />my representative. .-.r^cl\t=n <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: - ZLI _ <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: l -vZq —/ <br />Date Service Completed (if already completed): <br />SERVICE CODE: T2_ Zt�PIE:' <br />6o 1 <br />Fee Amount: ai <br />Amount Paid <br />S G — <br />Payment Date 7, q ,' s <br />Payment Type C <br />Invoice # <br />Check # (i, <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />