Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> fA00 Y,�L�12 S'�bb X35 <br /> OWNER/OPERATOR <br /> ` CHECK If BILLING ADDRESS <br /> -� <br /> FACILITY NAME I f (� <br /> �ltik C�+• IJ e W / / /� <br /> SITE ADDRESS ('c(Q �C�L��ic �VC�i STVCXTON (j ZOy <br /> Sheet Number I Direction Street Name CI ZI Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> (24) q 7c g037 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR -Do A t/ t CHECK If BILLING ADDRESS I� <br /> BUSINESS NAME P NE# Ear' <br /> J C. Ew Q�a zoq 1176, el037 <br /> HoNXor`AILINCCG ApDRES$)'), AX# ) <br /> CITYY L0 /�1 A II STATE Cif ZIP '/6-2-C'7 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized aent 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 /> 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: : 8 <br /> DATE: —Ztj 2.017 <br /> PROPERTY/BUSINESS OWNERJO <br /> OPERATOR MANAGER ❑ OTHER 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 provided to me Or <br /> my representative. - - <br /> TYPE OF SERVICE REQUESTED: Z20 O p <br /> COMMENTS: <br /> N W OWYv/r NOV 2 8 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT: <br /> ACCEPTED BY: MOO& MaqnQLhW1 <br /> EMPLOYEE M DATE: I P <br /> ASSIGNED TO: M�kihej EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: UZ <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> 07/17/08 <br />