Laserfiche WebLink
SAN JOAQL 70UNTY ENVIRONMENTAL HEALT_ EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />roc / /Ze die,/ / n <br />FACILITY ID # <br />fr----A-- 00 a 6 0 <br />SERVICE REQUEST # <br />,sie o o & / <br />OWNER / OPERATOR CHECK if BILLING ADDRESS <br />FACILITY NAME <br />VE.4/4-1- t 4 4-1 Alvk afaiirrtu„-J.5" Poo( <br />SITE ADDRESS <br />I (--;14 0 Street Number Direction <br />M 0k) aAl Street Name <br />4--D C4--ftY-N <br />City <br />Cl 5 -LC 7 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />4 7 c.) /-Tc) SO / C. 4-, , . A Y 9' a c *:TE) iv _ /.. <br />PHONE #1 Err. <br />Vi ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />C4/ 3 I'Vfr---7 .,-4---t-be--)/ D2 Pp---,e) 0.(.--'• //d--L3 <br />CHECK if BILLING ADDRESSEr <br />BUSINESS NAME e,.. <br />) <br /> ,-) <br />-- 4 Ct'' /0 ;41---- /7/C'1.--7 t. <br />PHONE # <br />(gQ') 4(76 -- 75 "2 <br />Exr. <br />HOME or MAILING ADDRESS <br />C f., pi-s• or cer . / . ..A.--,36);.2 <br />FAx # <br />(iir ) <br />Crry STATE ZIP <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:,, 2..P7Or7"2 DATE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <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 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: rept Ito 4,K () tov 1 tf`l 4 siV 4011 OWL S <br />COMMENTS: , RECEIVED 1 <br />JUL 2 9 2013 <br />SAN JOAQUIN COUNT( <br />ENVIROMENTAL <br />---- HEALTH DEPARTMENT <br />ACCEPTED BY: EMPLOYEE #: DATE: i _ 2.1 _ (3 <br />ASSIGNED TO: "-- d` EMPLOYEE #: DATE: -r _ 7, - , 7 <br />Date Service Comple ed (if already completed): SERVICE CODE: C 2.1. P / E:fi ta O __ <br />Fee Amount: 2..5 -0 e ......—• Amount Paid AO -- Payment Date /2,9,/,/ <br />Payment Type I, Invoice # Check # /1-- Received By4111,,1_..----1 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003