Laserfiche WebLink
SAN JOAQu4p __AL HEALTH *ARTMENT M <br />.AVJqKJZEQUEST <br />Type of Business or Property <br />IVIMI\ 14 ` i.. FACILITY ID # <br />EXIT- <br />PHor# <br />SERVICE REQUEST # <br />t` <br />ENVI RO MENTAL <br />o c� 13 tz <br />5 "- <br />OWNERIOPERATOR <br />CxFcx if BILuNG ADDI;Ess® <br />H6AL � D 60 <br />ACCEPTED BY: �� <br />FACILITY MW <br />DATE: t 1 <br />ASSIGNED TO: WL4 <br />EMPLOYEE #: <br />SITE ADDREss <br />Date Service Completed (if already - plated). <br />( u (t 5 ff <br />SERVICE CODE: t 3 <br />OiCii kl <br />w <br />gl j t <br />StreetNutnher <br />Dlr2ction <br />-E3 <br />street Name <br />1 Invoice # <br />-Csty <br />zip,Code <br />Received By: <br />HOME or NVILING Aciou-ss {If Different from <br />Site Address) <br />(� `1qq W �b <br />. t{� �t�,i 1 <br />s! �, 57eet Number <br />t flame <br />GfrY <br />1� 5 <br />STATE 1 <br />} , <br />P <br />EXT. <br />PHONE #1 <br />APN # <br />LAND USE APPLICATION # <br />2A,( \ <br />PHONE#2 i. EXY• <br />BOS DISTRICT <br />LOCATION CqPL <br />CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING AIJDRESSZ <br />611 3 1 �7�-%� Cr <br />13tISINEss NAME l�,R�1 <br />EXIT- <br />PHor# <br />HOPAE or MAILING ADDRESS �tG, ' a <br />FAX# zz <br />CITY `J E�� L1� 4 " C 5 2 STATE Z!P <br />BILLULG ACKNOWLEDGEMENT: 11, the umdersigrted 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 JOAQUtN <br />CouNTY Ordinance Codes, Standards, STATE and FEDuuL laws. <br />APPLICANT'S SIGNATYIRE: � i �� �' �: DATE: t'�'�'I <br />T <br />PROPERTY I BUSINESS OWNER© OPERATOR I MANAGER 0 OTHFR AuTHoRi'z8D AGENr�0 V eejhC �� � �Jy k f� <br />Iy.APPLIC✓tA-1' is not the BILliNG PARTY ,proof of authorization to sign is required vine <br />AUI'HOIRIZATION TO RFEASE INFORMATION: When applicable, I, the owner or operator oft e, property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or envirommzenta lsite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH .DEPARTmL-NT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SEMACE RECUIesTED: R i r ) <br />CO►t1Y9ENTS: <br />MEN <br />REcelve <br />MAR 17 201 <br />.SANEVORQI1FAj COLI <br />H6AL � D 60 <br />ACCEPTED BY: �� <br />EMPLOYEE <br />DATE: t 1 <br />ASSIGNED TO: WL4 <br />EMPLOYEE #: <br />DATE'. <br />Date Service Completed (if already - plated). <br />SERVICE CODE: t 3 <br />Fee Amount: d Amount Pai <br />3?Q. 00 Payment Date <br />Payment Type Vi :5,-- <br />1 Invoice # <br />Cfiep<# sr 6 jj <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 1 1 11 71200 3 <br />