Laserfiche WebLink
SAN JOAQUIZNI-a-UNTY ENVIRONMENTAL HEALTF ";,PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS JaJ <br />BUSINESS NAME ` ' �_�_���1 <br />1 T C.• <br />FACILITY ID # <br />PHONE# E.T. <br />`I b 1 - 33" <br />SERVICE REQUEST # <br />FAX# <br />(1ccl) '-16 � - 6 -2) <br />CITY \ C C \i ? - 3', <br />STATE ZIP CI'�.2 Q, <br />OWNER/ OPERATOF�, <br />CHECK if BILLING ADDRESS <br />C <br />A <br />1 <br />FACILITY NAME <br />SITE ADDRESS <br />C�.`t'�C e L_'�``� <br />�}E7CK.YC`r1 <br />��<52 e <br />Street Number <br />Direction <br />Street Name <br />Ci <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 <br />Ems• <br />APN # <br />LAND USE APPLICATION # <br />(�0(I) �I l -c <br />_S - <br />PHONE#2 <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />�J C <br />CHECK if BILLING ADDRESS JaJ <br />BUSINESS NAME ` ' �_�_���1 <br />1 T C.• <br />PHONE# E.T. <br />`I b 1 - 33" <br />HOME or MAILING ADDRESS <br />2 O PIL <br />FAX# <br />(1ccl) '-16 � - 6 -2) <br />CITY \ C C \i ? - 3', <br />STATE ZIP CI'�.2 Q, <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 laws. <br />APPLICANT'S SIGNATURE: �� fL/�,_l. ___ DATE: U'�i <br />PROPERTY / BUSINESS OWNER ❑ O ERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT <br />IfAPPLICANT not the ILLINGPARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELE 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 �,t the same time it is <br />provided to me or my representatives.. '(MStr1-UX1 <br />TYPE OF SERVICE REQUESTED: L�� I �2�_CJ F— / FkE <br />COMMENTS: JkJJJ , O <br />JOAwm GOVNN <br />SASNVIftONMENTAt- <br />HEpt.TH DEPARTMENT <br />ACCEPTED BY: L -t �i EMPLOYEE #: 3 Z DATE: I D Q <br />ASSIGNED TO: EMPLOYEE #: C� (f ( DATE: 0/0 <br />Date Service Completed (if already completed): SERVICE CODE: P 1 <br />Fee Amount: Z �l , cu Amount Paid �sa,-1, tm Payment Date Ll. "o C7 (� <br />Payment Type Invoice # Check # �'S3� Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />