Laserfiche WebLink
SAN JOA( COUNTY ENVIRONMENTAL HEALODEPARTMENT <br /> SERVICE REQUEST <br /> SERVICE REQUEST# <br /> Type of Business or Property FACILITY ID# <br /> 1-� C90 D�l,� <br /> OWNER/ ERATOR r <br /> CHECK If BILLING ADDRESS <br /> 0.Y2(2 <br /> U A {/ <br /> -FACILITY NAME u1 C(C P <br /> SCS% r 6G a 1 <br /> SITE ADDRESS $yL>< 1)� ��i-�Uti� �C A- M <br /> Street Number Direction Street Name City zip cod. <br /> }IdME or MAILING ADDRESS (If Different from Site Address) �z.3 I a to"h GkG <br /> reef Number Street Name <br /> OJTCICiCG'�(�l� STAT <br /> PHOJIE#1 E-. APN# LAND USE APPLICATION# <br /> -201) __ it 003 <br /> E#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( I © } v l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME <br /> PHONE# ExT. <br /> HOME or MAILING ADDRESS FAx# <br /> 1 ) <br /> CITY 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 rdinance Codes,Standards, TArd FED L laws. /J <br /> A_ LICANT'SSIGNATURE: ✓ DATE: <br /> I- �3" � <br /> RO BUSINESS OWNER❑ OPERATOR/MANAGEROTHER AUTHORIZED AGENT 13 <br /> IfAPPL/CANT is not the B/LLINGPARTY 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 environme I/site assessment <br /> information to the SAN JOAQUIN COUNTY ENvtRONMENTAL HEALTH DEPARTMENT as soon as it is available antime it is <br /> provided to me or my representative. `- 1 A� ^ <br /> TYPE OF SERVICE REQUESTED: l�y� {�1A5(,f,� /jA. LOQ ,}./� l{r7wf> �'4iV y <br /> COMMENTS: �/jtlAGu (�W7WHV' y FN�q at X14 <br /> 0 <br /> EACTy�Aq��Nry <br /> MFM, <br /> ACCEPTED BY: Q^ EMPLOYEE#: DATE: I z 3 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: D 6 PIE: <br /> Fee Amount: t -15- v Amount Paid �as D� Payment Date 123 <br /> Payment Type. Invoice# (.� Check# Received By: <br /> EHD 48-02-025 �R(�bI- 'I SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />