Laserfiche WebLink
0 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />H <br />CHECK BILLING ADDRESS <br />FACILITY ID # <br />SERVICE REQUEST # <br />En. <br />C ` SZZ. SI1 0 <br />M -` <br />HOME or AILING ADDRESS 'Z(..O <br />��-V <br />:o-1-7oo <br />OWNER/OPERATOR <br />—" --- <br />`(n G r—' <br />- <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />Y i, F Ir1-6tb ISj <br />I <br />SITE ADDRESS I S 3-S: <br />1�-7.�° <br />DATE <br />Date Service COD7pleted (if already comp ted): <br />SERVICE CODE: <br />Street Number <br />Dir u., <br />—rc' <br />fleet Name <br />1t l' _. <br />Coda <br />HOME or MAILING ADDRESS (If Different from Site Add <br />/, <br />Street Number <br />treat Na <br />CITY <br />STATE LP <br />Check"(ArIi�A7BC32 <br />/% <br />PHONE #1 En.. , ' <br />( ) <br /># <br />LAND USE APPLICATION # <br />PHONE #2 En. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR * <br />REQUESTOR <br />ot) Gvt7 S`l <br />H <br />CHECK BILLING ADDRESS <br />BUSINESS NAME J ,\ f <br />0 <br />'TA UL -`1 v°Ro� cou <br />H��DE <br />En. <br />C ` SZZ. SI1 0 <br />M -` <br />HOME or AILING ADDRESS 'Z(..O <br />- RAL P ,o 1 A 0-4 Q.b,It GLA sh 19 azOth cbmp tci60 <br />Z <br />FAX# <br />CITY. HEj� l Y C+4L- <br />STATE LP F:� `S U <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project spp ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me ( my bust es Identified on this form. <br />1 also certify that 1 have prepared this <br />COUNTY Ordinance Codes, Standards, <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER ❑ <br />JfAmic,tw is not the <br />that the work to be performed will be done in accordance with all SAN JOAQlnN <br />IERAL laws. <br />DATE: 2 • Z.'J • 14 <br />VAGER ❑ OTHER AUTHORIZED ACENT P ft4a-. M A(Y A W t <br />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 environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sang ee It is <br />provided to me or my representative. "EIV <br />TYPE OF SERVICE REQUESTED: <br />CowENTs: <br />`tA(�C SNE (76AVL oIL <br />0 <br />'TA UL -`1 v°Ro� cou <br />H��DE <br />tJ, or- s6fL�U1G6 <br />�RiME <br />,t?1ILC TNS. AaaL mbQ_ "* <br />- RAL P ,o 1 A 0-4 Q.b,It GLA sh 19 azOth cbmp tci60 <br />Z <br />)A <br />ACCEPTED BY: „t <br />EMPLOYEE #-. <br />DATE: <br />ASSIGNED TO: I '�CCGL1�11(ti. <br />EMPLOYEE#: <br />DATE <br />Date Service COD7pleted (if already comp ted): <br />SERVICE CODE: <br />P I E:_2 <br />Fee Amount <br />—rc' <br />Amount Paid <br />1t l' _. <br />Payment Date 3/y1 <br />/ <br />PaymentType VllSjL <br />Invoice# <br />Check"(ArIi�A7BC32 <br />ReceivedBy:t,6, <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />