Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT '�(Zo 0-7S 5q <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> OWNER I OPERATOR ff <br /> Fe7 �-j CHECK If BILLING ADDRESS <br /> FACILITY NAME / Jw��u-r [� <br /> SITE ADDRESS /^7 (� Jc-v !v 1� � r I 'q5-377 <br /> J Street Nurn6er Direction Street Name J Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) /nns7 T� Vl <br /> A, 5trreeeett Nu G Street Name <br /> CITY 1j}ct_ r WAJ 5fh� STATE P 4 ZIP <br /> PHONE#'I /� Exr. APN# LAND USE APPLICATION# 47 / <br /> (Ye) dOZ(oZ-73 7-S7-' <br /> PHONE#2 Exi. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR r SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADORES <br /> BUSINESS NAMEPHONE# �' <br /> b I A-mOM -- E461 MUM 44---3 7-7-S <br /> HOME or MAILING ADDRESS FAx# <br /> 70 <br /> CITY STATE O ZIP i4q J S t�1 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that aN 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 /> also certify that I have prepared this ap lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S A E and FED <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER D OPERATOR I I4XGECE1 'OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARrr,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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the Same time It Is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: N>c 1;ONI TZ-f jLOTP-0 F I �~ <br /> COMMENTS: <br /> ]PI 9122D19 <br /> ENVIRONMENTAL HEALI H <br /> ACCEPTED BY: EMPLOYEE ; <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07117/08 <br />