Laserfiche WebLink
lie <br /> SAt4 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> T�pe of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �Alnm f�pd bAt P-00 ---7 1Xq <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS E] <br /> FACILITY NAME )� n0S <br /> SITEADDRESSN ` bpYGt GJ 6 <br /> 1 �01Street Number Direction Street Name City Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> (Z ) 3 U4g5 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) '75�— $4a ► © ► <br /> CONT_ CTOR SERA E REQUEST®R <br /> REQUESTOR ( 'O <br /> '`'p✓A� CHECK If BILLING ADDRESS .d <br /> BUSINESS NAPOEI PHONE# EXT. <br /> (.ams cL 5 <br /> HOME or MAILING ADDRESS ` , FAX# <br /> CITY Lill, ^' n, ` STATE / /L ZIP C7 <br /> BILLING 1'ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent jof same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this pp'cation d t at the work to performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, T E an ED L laws. <br /> APPLICANT'S SIGNATURE: DAT,�E-:� �� <br /> PROPERTY/BUSINESS OWNER❑ OPE T R/MANAGER ❑ OTHER AUTHORIZED AGENT [fit VI <br /> If APPLICANT is not the BILLING PARTY proof of authorization t0 sign is required l Tirfc <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It IS provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: �la� ��� '� <br /> COMMENTS: <br /> N�otiJ �Ulme,✓ — 2F.�,���-� <br /> RECEIVED <br /> JAN,26 2015 <br /> SAN JOAQUIN COUNTY <br /> ENVIR_OMENTAj _ <br /> ACCEPTED BY; �/� y�� EMPLOYEE$#: M _EPA TM <br /> ASSIGNED TO: �l ► j^ /,1,W <br /> _!`_s':-! ' EMPLOYEE fr: DATE: <br /> Lo <br /> Date Service Completed (if already completed): SERVICE CODE: 5z3 1 <br /> PIE: ' �O 1 <br /> Fee Amount: - O Amount Paid --�av) Payment Date <br /> Payment Type Invoice# Check �eJ `—j Received Ey. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />