Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH liEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Rei i 1 U�' i coo1i 000 a? '�llo S Ko E) <br /> OWNER/OPERATOR nr V(J l'I <br /> P 1w I�s L � y A�U LLC <br /> FACILITY NAME CHECK If BILLING ADDRESS <br /> �� 1 <br /> SITE ADDRESS <br /> '`� C) YJ r �J` <br /> too Street Number Direction M4 Street N L • KJCi Zi 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 /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I <br /> V1 IVo') m c&�'k u CHECK If BILLING ADDRESStf <br /> BUSINESS NAME 1 (4 PHONE# / EXT. <br /> 7>• 5b7- V <br /> HOME Or MAILING ADDRESS' n �� �. ,1 n� +� CA, � <br /> CITY YV IVV ` STATE CA <br /> ZIP 2 80V <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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: a. t' IAL L-tD 3�0 DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR PMANAGER ❑ 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 <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 at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: S C is ; } ECEIV ED <br /> COMMENTS: I 0 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: R V n"'-J t(^-/ EMPLOYEE#: a 3� DATE: Z )� <br /> ASSIGNED TO: Pvatj f-�(�� EMPLOYEE#: (! t DATE: • O 0 K <br /> c <br /> Date Service Completed (if already completed): G7 O SERVICE CODE: P J E: 'Z Q <br /> Fee Amount: Z 0 v Amount Paid i 2-74�,Cro Payment Date 2 Ip 0LI <br /> Payment Type Invoice# Check# —1 a(p Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />