Laserfiche WebLink
SAtt JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />PHONE <br /># <br />HOME or MAILING ADDRESS <br />13 23 S wtlsorl wcty AeT3 <br />FAK# <br />( ) <br />�^ <br />'f 002-1 0-+S <br />/S�ERVICEREQUEST <br />' K 009 (P ?bH <br />OWNER I OPERATOR <br />7 L <br />Luh y <br />EMPLOYEE#: <br />DATE: <br />CHECK If BILLING ADDRESS <br />'J <br />FACILITY NAME 4--p yc0W-A <br />T I <br />L404333y2MZ <br />Date Service Completed (if already completed): <br />SITE ADDRESS <br />S <br />Ci.(.I I roV <br />IIIQ S}- <br />Amount Paid <br />S+OC(C-�-191`1 <br />n <br />7 Street Number <br />015 on <br />Check # <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />VV, i I So h VV e" y <br />)3-2---2, S <br />Street Number <br />Street Name <br />CITY .J C 40 C n <br />�' H STQTE„ ZIP <br />PHONE#t Ems' <br />APN # <br />LAND USE APPLICATION # <br />(toy) 9zz-170¢ <br />PHONE#2 Em <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />J(-0)2— <br />CHECK If BILLING ADDRESS <br />,/� <br />BUSINESS NAME LA I <br />1A "C, ;W333 21`12 <br />PHONE <br />Zz — Exr. <br />HOME or MAILING ADDRESS <br />13 23 S wtlsorl wcty AeT3 <br />FAK# <br />( ) <br />CITY C t _C I ',e', STATE <br />ZIP Gj s—ZC <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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: Lut5 L Llamoas DATE: �� — �_Q� Ld,LZ <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />/f APPLLCANTisnatthe BLLLLNGPARTY proof ofaulhoriZation to Sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 environmentat/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available a*ftgaarne time it is <br />provided to me or my representative. ROS_ ENT <br />TYPE OF SERVICE REQUESTED:MA I <br />FD <br />COMMENTS: <br />9 Jn� <br />ENVIRpA, E 0(/ <br />�Oepm <br />7 L <br />ACCEPTED BY: <br />EMPLOYEE#: <br />DATE: <br />ASSIGNED TO: I YL <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type 1 <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />