Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �04 Flo U 5F vo c w` i <br /> OWNER/OPERATOR <br /> FACILITY NAME X � / W1~� COAK ATI 0^ <br /> CHECK If BILLING ADDRESS <br /> / /O <br /> 1100(JE <br /> SITE ADDRESS 3 SS g VI/. HAIIA)" 'g 1--N TTT—ock7-ml cl---2 1 / <br /> Street Number I Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY j��I�i' _J STATE C/J, ZIP <br /> PHONE#11 ` V\(�I l= EXT. APN# LAND USE APPPIILCCATION# <br /> PH IV1 #2 EXT. BOS DISTRICTLOCATION CODE <br /> ( Jl Y 9 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR '^ C-C(✓1 1 v/��,y <br /> r l r J CHECK If BILLING ADDRESS <br /> S S_ <br /> (120 <br /> BUSINESS NAME j ,S �I D � � U r (l� # EXT. <br /> � <br /> HOME or MAILING ADDRESS b L�e I FAX# <br /> J C/JI ( i <br /> CITY C1 �v� _I (� STATE �/ ZIP <br /> 6 61 <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 nd FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: { DATE; 0 / 2 3 2 10 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTVR AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS prj ded to me or <br /> my representative. 7q <br /> TYPE OF SERVICE REQUESTED: EIC <br /> COMMENTS: <br /> Jut 2 3 20 <br /> 19 <br /> �RQU <br /> ovjntf HN1lly COUFTH �Vhf q,DRClvrr <br /> TMENT <br /> ACCEPTED BY: L✓L�1�/l EMPLOYEE#: C ) DATE: 3- 16 <br /> ASSIGNED TO: l �Vil EMPLOYEE#: l/ DATE: 7 <br /> Date Service Completed (if already Completed): SERVICE CODE: Gy/r/ PI E: <br /> Fee Amount: I 60 Amount Paid 1S� Ov Payment/Date 7 J <br /> Payment Type Invoice# Check# d� �� ecei ed/By <br /> ;6 : <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> �1�-o�ip�.9.0 <br />