Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />/1 /°•4 <br />FACILITY ID # <br />2_ o C,,, 6 <br />SERVICE REQUEST # <br />L5 15 -216/ <br />OWNER! OPERATOR CHECK if BILLING ADDRESS <br />FACILITY NAME <br />(J 00C1 e-s+a-le, <br />SITE ADDRESS <br />c97d 7 Street Number Direction <br />S L.) irk" Yin CV 'PG ifl d <br />Street Name <br />.S111-A <br />City <br />9,S-,910 7 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Cm STATE ZIP <br />PHONE #1 <br />( ) <br />EXT. APN # <br />07e —apo'39 <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. BOS DISTRICT 3 LOCATION CODE <br />( <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTDR r, P CICLaGt c <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />C 0 S40 VI-• '1) (3.0 QI a s-kr ; tvi <br />PHONE # <br />( do 5 ) <br />EXT. <br />5-- 3 )- (oSt 6 <br />HOME or MAILING ADDRESS <br />SdOC.) ,A104-S;/4.5.e V <br />FAX # <br />( d-of ) 53 7 - to <br />an( Oekres STATE cA, ZIP 9s-3,2 <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, STAT d FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: ,P <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 <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: P__4) C-- ILIZ c_pc_c____T-?_e 4-€,J,--todec_ P L--,tn) C f-4 ECCC_ <br />COMMENTS: PAYMENI <br />RECEIVE <br />MAY -8 20 <br />SAN JOAQUIN CC <br />ENVIRONMENT <br />HEALTH DEPAF1T1 <br />ACCEPTED BY: out. vEt tejt. EMPLOYEE #: p3 2_4 DATE: _s---(P-(o ? <br />ASSIGNED TO: crjeHeie Es. co EMPLOYEE #: 04 (42 7 DATE: 5141.0 q <br />Date Service Completed (if already completed): SERVICE CODE: .5- 22_ PIE: <br />Fee Amount: cg ' \ , Amount Paid -,E,01, D . 50 Payment Date 3( syd 7 <br />Payment Type --' Invoice # Check # / DI 0 7 Received By: <br />Title <br />09 <br />NTY <br />AL <br />ENT <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod)