Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> �- SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> /,S-/ -7 Seo 3r � <br /> OWNER/OPERATOR <br /> CHECK it BILLING ADDRESS <br /> FACILITY NAME <br /> C1, I1 C <br /> SITE ADDRESS 3 9 o o �' ac /TY n H L Ci)0Y YZ L. "{ S .3 7 <br /> Street Number Direction Street Name Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Addre )�.t <br /> 9 /V TY 'Tr SIf Street Number Street Name <br /> CITY / Y.(� ,/1 STATE ZIP <br /> PHONE#1 EXT. APN# �••�- LAND USE APPLICATION# <br /> ✓`I) Fs IL4 o • 213 - 0&0 —/ (� <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHON # E%T. <br /> HOME or MAILING ADDRESS FA%# <br /> e ( ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/or prof eet 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 and FEDERAL laws. r` ' / <br /> APPLICANT'S SIGNATURE: DATE: l I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> IfAPPLLCANTis not the BLLLtNGPARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: USE T" 4�C7Y–O lc t 7– <br /> COMMENTS: C+ <br /> v%ql <br /> M t_C" El cE- f4-Iic—, J✓ v - a , 10 <br /> o <br /> PN�O P�NMPP t� <br /> ACCEPTED BY: O L{Vet 1� EMPLOYEE M D DATE: <br /> ASSIGNED TO: 1E A) EMPLOYEE#: SC, Z DATE: 7 a S <br /> Date Service Completed (if a ready co leted): SERVICE CODE: !o Q' IE: (�� <br /> Fee Amount: zc/ Lj �2–'-1;'I'4mount Paid -0 sg$" Payment Date ' <br /> Payment Type v Invoice# Check# /T_�I��� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />