Laserfiche WebLink
-rj r 0.7 <br />EXT. PHONE # <br />STATE ZIP /915:3 0 r,„7. <br />410" el-11.-1'1.1124 31:t_grArdalifidetipOr - - .y.;P:a0te4) 4, • <br />BUSINESS NAME <br />u, c-fro eY) POO gen-ladd <br />5aix) at" <br />REQUESTOR <br />HOME or MAILING ADDRESS <br />CHECK if BILLING ADDRES.Ma <br />37-63-(=c2 <br />Fax# <br />04' ) <br />SAN JOAQUIN JUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />A 14-ii-A•telf <br />FACILITY ID # <br />A /&i/ <br />SERVICE REQUEST # <br />g bOt, 1 - e 1 ci--7 <br />OWNEI / OPERATOR <br />/29( d,S:56C , 1)1+7 A-,,c-/-,1 o I- <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />Ver7;/),14,7 C74),4,7_S <br />SITE ADDRESS <br />j5SY Street Number Direction X094/ C Street Name Sitt/Le/1 City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Om STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <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 DERAL laws. <br />APPLICANT'S SIGNATURE: DATE: g-- <br />PROPERTY / BUSINESS OWNER 0 0 RATOR / MANAGER 0 OTHER AUTHORIZED AGENTA (- <br />If APPLICANT is not th ILLING PARTY, proof of authorization to sign is required Tide <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 environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: CtIT CY \i * PP\'\( <br />COMMENTS: <br />FA - rg:Eft4V-SYWL- <br />vos5"0EY <br />DATE: <br />247141"/ <br />ACCEPTED BY: 514-1H EMPLOYEE #: 1.1,R-b <br />ASSIGNED TO: r-Aegue..-tD EMPLOYEE #: (...0 4421- DATE: <br />Date Service Completed (if already completed): SERVICE CODE: de P I E: 5v0 ,.. <br />Fee Amount: <br />i 61:C. CA <br />Amount Paid erp5-- — Payment Date (3.- aq. f/9 & <br />Payment Type v/ 4, 61)6g, Invoice # I Check #20,1,V Fl. Re eived By:g_e <br />EHD 48-02-025 <br /> j v <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003