Laserfiche WebLink
SAN JOAQUWOUNTY ENVIRONMENTAL HEALTH&PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAM <br /> SGk.�br, �7��oa v n <br /> SITE <br /> ADDRESS 2b�Y ItUe 1�7i � w�iCJ�Y ��� �"IUCk_ bYN 11152-02— <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Lvq) �33 - 1156 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> y{ a I a�"+e_ - CHECK if BILLING ADDRESS <br /> BUSINESS NAME 1 PHONE EXT. <br /> -k b G k�o� "C�+-I o 0 C-0 M an Zb 3 - 11 <br /> 5 0 <br /> HOME Or MAILING ADDRESS E f ,n �-e y- <br /> Ave- <br /> CITY <br /> v� (�# <br /> CITY 54-o k 1 L� w CJ I/�I 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,S TE and FEDE laws. <br /> APPLICANT'S SIGNATUyR�E/: � � DATE; / 2- // Z / / GJ <br /> PROPERTY/BUSINESS OWNER IJ OPE TOR/MANAGER ❑ 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available ane same time it is <br /> provided to me or my representative. ,% j•n <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> /y, <br /> cTti�FpgR Mq4 7Y <br /> FNT <br /> ACCEPTED BY: ` v, EMPLOYEE#: DATE: �2 <br /> ASSIGNED TO: EMPLOYEE#: qg) DATE: 2 <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: Amount Pai Payment Datea12-11211 <br /> Payment Type Invoice# Check# Recei d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />