Laserfiche WebLink
SAN JOAQUIP JUNTY ENVIRONMENTAL HEALTH'L _'ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK if BILLING ADDRESSIV <br />SERVICE REQUEST # <br />G, A'S srAI-rto" <br />f <br />EXT. <br />Ql_�r- 603 � <br />drkb o s 6 <br />OWNER / OPERATOR <br />FAX# <br />(4M <br />-22— %00 a(j <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />zip Q S'' If <br />SITE ADDRESS <br />�'�St�r'e1'e`t!N''umber <br />W <br />i <br />r <br />N <br />Tv C <br />q5,57(4 <br />(" I <br />Direction <br />Street Name <br />�, <br />Ci <br />Zio Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Payment Type <br />✓ <br />Street Number <br />Check # 11 +2__ <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT <br />S <br />LOCATION CODE <br />( ) <br />C -C <br />CONTRACTOR / SERVICE REQUESTOR I <br />REQUESTOR <br />ENVIRONMENT 1 <br />CHECK if BILLING ADDRESSIV <br />BUSINESS NAME <br />S•earvt;C,e. S tc 5 sfp-- s zinc . <br />PHONE # <br />0 <br />EXT. <br />Ql_�r- 603 � <br />HOME Or MAILING AD ESS <br />/U �V -ILAAA AQ -e, <br />FAX# <br />(4M <br />-22— %00 a(j <br />CITY t S -f— <br />STATE (?A <br />zip Q S'' If <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 JOAQOTN. <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT.'S SIGNATURE:' r <br />(%t.�trlrl., DATE:... `�.• `ab67 : ..:: ' ',,,.' <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is requiredT !e <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the pro Q4 ED <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmenta sl a as <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sa171� t{rl•1� it„igo7 <br />provided to me or my representative. MAi j [U I <br />TYPE OF SERVICE REQUESTED: 'od—z <br />ENVIRONMENT 1 <br />COMMENTS: <br />/ 4160 SuuSto. (I l. <br />Mq y 3 <br />S�N J <br />ACCEPTED BY: <br />O L (J f <br />EMPLOYEE #:DATE: <br />LSI PNM <br />J <br />ASSIGNED TO: <br />r <br />N <br />EMPLOYEE #: r �Jr <br />I <br />DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 1 Ct3% <br />P <br />a <br />Fee Amount: 4S. <br />�, <br />Amount Paid�oZgS 0c, <br />Payment Date <br />S -/3l O <br />Payment Type <br />✓ <br />Invoice # <br />Check # 11 +2__ <br />Received By: (,,:!j <br />EHD 48-02-025<'%I /� /' SR FORM (Golden Rod) <br />REVISED 11/17/2003 /�/ <br />C <br />:ALTH• <br />SES <br />�VN7' <br />Eo <br />