Laserfiche WebLink
_� —�..,.... .. . .u�v....aAs..A ti xxGA' 1 UIJEFALKLIVIEN'IF <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> --t� <br /> OWNER/ ODPWIITnR 7/� <br /> \ ` \ \/Le` CHECK If BILLINGADDRESSE] <br /> FACILrrY NAME <br /> SUE ADDRESS lb ) <br /> � — •�— \ r, S <br /> Street Number Direction Street Name i �!•` Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> S tuber Street Name <br /> CITY STATE ZIP <br /> PHONE#t APN# LAND USE APPLICATION# <br /> PHONE# Ear. _BOS DISTRICT <br /> ( 1 LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO� e <br /> `�.J�,S'� �, \VIZ CHECK If BILLING ADDRESS <br /> �BUSINESS NAME + ^ ^ 'yf 1 �{' ..{xr���� l•`/IJLy�I J 4 W l ��+/V 1 <br /> HOME Or MAILING ADDRESS wj-> <br /> ��v"1Jxr 4 1 -I�3 `a <br /> CITY STATE C A ZIP �O ' <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 or <br /> 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 Ordinance Codes,Standards,STATE and FEDERAL law' <br /> APPLICANT'S SIGNATURE DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑. CAR AUTUORizED AGENT UIC9_ -Wtx�U <br /> IfAPPLICANT is not the BLLLDVCPAR7Y proof of authorization to sign is regufredr Titre <br /> AUTHORIZAT76N 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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> ``- provided-tome or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> —_- fee Amount: Amount Paid <br /> Payment Date <br /> -- - Payment Type- Invoice# Check# <br /> ReceivedBry. <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 .�3,� <br />