Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT � <br /> COP <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> /,�,k-0 - r 1 CHECK If BILLING ADDRESS <br /> �� <br /> FACILITY NAME �� My <br /> [a'ROuNQ <br /> SITE ADDRESS /-"j �fHyl <br /> 7(StGreet Numher Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) �nt1 {� � ��)✓ <br /> /� Street Numher / 1� Street Name <br /> CITY / 19e'/t/! - t/VJAJ�� STATE 4 Zip J57Qe <br /> PHONE#1 1#19e <br /> Ems. N# LAND USE APPLICATION# <br /> (yrz)AW Z&2--73 7Y, -2.(5 6 <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADORES <br /> BUSINESS NAMEb I A-rno�c� �j ��� PHONE# 7 Ex r. <br /> HOME or MAILING ADDRESS FAX# <br /> Sb70 15 [ ) <br /> CITY+^J STATE C) 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 ENMRONMENTAL 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 /> 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, Standar7SAE and IFF- <br /> APPLICANT'S <br /> eAPPLICANT'S SIGNATURE: DATE: <br /> PROPERTY t BUSINESS OWNER❑' OPERATOR/ ANAG R ❑ 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the SaIR <br /> e I p <br /> my representative. <br /> PAa map!1113111VICE REQUESTED: �� "t;, 1 7 jc-`' TL�p�1 3` t <br /> R VSD <br /> A 0 a 2018 ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br /> SAN,IIRONMENTALOAQUIN TM <br /> HD EMPLOYEE M ,r I DATE: <br /> � `F1 Y: _ _ y� <br /> ASSIGNED TO: l/� 1 Oi�� EMPLOYEE M 0l{J(o 111 DATE: 1-1 <br /> Y -1 t! <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: rat <br /> Fee Amount: Amount Paid aT D(7 Payment Date <br /> Payment Type Invoice# Check# '70 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />