Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property �n O6-7�qa� <br /> I p��qp <br /> 6� NER f OPERAT 7 _ CHECK iF BILLING APOREss r <br /> FACILITY NAME `4 <br /> YK.A.Z�c�vl Y� <br /> .i 4v dr�iV� � Str.eet7Atv Q� db <br /> ITSE ADDRESS gtv �f -1" <br /> amez e <br /> Street Number Dlrectlo+• <br /> HOME or MAILING ADDRESS (If Different from Side Address) <br /> 1p�m Street Number Street Name <br /> CITY STAT, x ZIP <br /> i .JlA� <br /> YT. APN# LAND USE APPLICATION# <br /> l'-0NE#1 1�� I 2,���0() <br /> ( ZOR 6-10 <br /> P ONE 42 EXT. r3G•S©1STRIGT LOCATION CODE <br /> J CONTP .0 Goff./ S R V ICE REQV STOR ' <br /> E:QUESTOR j� n t �) o�LA CHECK if BILLING ADDRESS <br /> PHONE# EXT. <br /> BUSINESS NAME � V-) 2d� � � 7 <br /> VV�,6L"L.. v <br /> HOME orftfAtLIy2S ESS j f _ FAx# <br /> CITY STATE �1, tP E Zl Z <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site andlor project speclftC 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 /> 1 also certify that I have prepared this applic on and t t e work t e performed will be done in accordance with all SAN JOAQUkN <br /> COUNTY Ordinance Codes, Standards, STATE n FERE a s. F j � <br /> APPLICANT'S SiGNATURE: DATE: CO) +! <br /> PROPERTY I BUSWESS OWNER J� OPERATOR/ ANAGER OTHER AUTHORIZED AGENT 0 <br /> If APPLICANT✓✓✓✓✓✓is not the BILLING PARry,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, E, 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. PAYWNT <br /> E-1 <br /> PE OF SERVICE REQUESTED: r >v <br /> REOEWED <br /> COMMENTS: <br /> AUG 10 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: r EMPLOYEE#: DATE: �• l O - <br /> ASSIGNED TO: I SC11 1l EMPLOYEE#: DATE.: <br /> Date Service Completed (if already completed): SERVICE CODE: /�/ r'?E: (CD2 <br /> Fee Amount: Amount Paid 13 Payment Date 62-6 rto ( b <br /> Payment Type _ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> S <br />