Laserfiche WebLink
AN JOAQUIN LOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR , <br />CHECK if BILLING ADDRESS i 67 )0 r? <br />(a_r..c <br />FAciurY NAME <br />4.----1 Pt— <br />SITE ADDRESS ‘ 120 Cg'.1e.A W 1 <br />Street Number Direction <br />' .g:k PCDY-1. CA G1 W --12 <br />Street Name City . Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY <br />PHONE #1 EXT.G1, <br />STATE ZIP <br />0 <br />ILAND USE APPLICATION # <br />PHONE #2 EXT. Ii <br />( ) <br />BOS DISTRICT LOCATION CODE <br />PIP <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME A. <br />EXT PIM )c.-2,1463) _Lo c,,z Li <br />HomE or MAILING ADDRESS cgt \, \ e:)1 v61 <br />. <br />F <br />(In ilA0kUV4,La <br />CITY manA_era STATE ZIP Clo..3(.40 <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 ap ca on and that the work to be performed will be • one in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ATE and FEDERAL aws. <br />APPLICANT'S SIGNAT <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite 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: ifUer/V 4i. <br />I "-A I IVIMIN I <br />RECEIVED <br />COMMENTS: MAR .. 7 e 08 <br />SAN JOAQUIN COUNTY H ENVIRmi --MENTAL TII DEPARNENT <br />ACCEPTED BY: <br />K (.— <br />EMPLOYEE #: 1)( DATE: <br />ASSIGNED TO: <br />?Ve(ir:75E0 <br />EMPLOYEE #: 0 c/...(g DATE: <br />Date Service Completed (if already completed): SERVICE CODE:_c2 PIE: .70 / <br />Fee Amount: ci t) Amount Paid 3 6 2 , Cl.Th Payment Date 3J7/ <br />Payment Type ----- Invoice # Check # 7 6 7 I Received By: <br />DATE: <br />EHD 48-02-025 SR FORVII:Oki6ri'k'od) <br />REVISED 11/17/2003