Laserfiche WebLink
JAN JOAQUIN UOUNTY to NVIRONMENTAL HEALTH I)EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Go,g �D&,NO�?q <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS El <br /> FACILITY NAME <br /> SITE ADDRESS . � ` Or �� �" <br /> Streo[Numbcr 6lrectlon ` c/,/ 9s-2,112- <br /> Streat Namc CII ZI Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> GIN Slrecl Number Street Namc <br /> /600� STATE Zip <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (2 CT 333 Q$3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> 20 2 <br /> HOME Or MAILING ADDRESS FAX If <br /> In 7 Lo zLl ( ) <br /> CIN 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 project SpeCifiC ENVIRONMENTAL HFALI'li 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.IOAQUIN <br /> COUNTY Ordinance C'ocles,S7ara/m'dY,STATC and FFDFRAL laws. <br /> APPLICANT'S SIGNATURE: /�I� DATr,: �( ' y G y <br /> PitOPER7Y/BUSINF.SSOWNRIt❑ OPERATOR/MANAGER ❑ OTima AlrrHORIZI?D AGFIN•t'❑ <br /> ?f'AvNLlGIN7'is mar rGe BILLING P,1/n'Y proof ojaardoriznrion ro xign is repairer! Tine <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator or the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or cnvironmenlal/site assessment <br /> inrormalion to the SAN.IOAQUIN COUNTY ENVIRONMENTAL HFALTII DFPARTMFNT as soon as it is available and ;it the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: z27 <br /> vt�7 <br /> Nw 4J <br /> SAN'JOAQu <br /> 8 200 <br /> HtAt 1VME1u�fy <br /> RTtI,f � <br /> ACCEPTED BY: EMPLOYEE#: G' �( Q I DATE: I F' <br /> AsSIGNEDTO: EMPLOYEE 4 I DATE: tI <br /> Date Service Completed (if al ea ompleted): SERVICE CODE: Id <br /> Fee Amount: D Amount Paid Payment Date l =�'C• <br /> Payment Type Invoice# Check# 2 it Receiv d By: <br /> EHD 45-02-025 L.J (/ SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />