Laserfiche WebLink
SAN JOAQI TIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />R'es, <br />FACILITY ID # <br />61) 6-00 / 2 0C, <br />SERVICE REQUEST #. <br />.5.--('‘) b y /// <br />OWNER/OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME - <br />illia aeildi 5 <br />SITE ADDRESS <br />//CZ? Street Number irection ii..,•64-41' /e, Street Name <br />cti-tAvierl7 <br />City <br />q3-2,0- ? <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name - <br />CITY STATE ZIP <br />1. .. <br />PHONE #1 EXT. <br />( ) <br />APN # LAND USE APPLICATION # a <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />( V 141144/4 <br />CHECK if BILLING ADDRESS El-- <br />BUSINESS NAME <br />i‘f L7/7 fie, PHONE # ExT. <br />c.901)3,1‘-/ ,231.1.? <br />HOME 114-MAILING!2k1i) R <br />tje aa' 7/a. <br />FAx# <br />( ) 3 '3`i - 6'J2> <br />CITY /4 c• STATE ..---,,, ZIP9:5-4 (9.43,..-- <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE • EDERAL laws. <br />APPLICANT'S SIGNAT Jjia rP --/ ....._______./ <br />DATE: .. / -(e) <br />PROPERTY / BUSINESS OWNER OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLI 7 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: U C5P) <br />COMMENTS: /qECE-/VNT ED <br />JUN - 1 2010 <br />-AN JoA „, ENvnio--N COUN "(PAL NmE Ty TH DEp, ,NTAL <br />-in TMENT <br />ACCEPTED BY: EMPLOYEE #: (egy 7) DATE: 0 6 / To <br />ASSIGNED TO: ir./24941, EMPLOYEE #: p ....1 3 DATE: C 0 / 7> <br />Date Service Completed (if already completed): SERVICE CODE: .... P / E: <br />Fee Amount: $ D, 50 ot) Amount Paid 0.. 3 a _ Payment Date L,/ ‘.) t 0 <br />Payment Type c...,.--- Invoice # Check # S 2_ k % Received By: <br />END 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003