Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -FA 0o zC5 <br /> OWNER/OPERATOR , I '^ i <br /> t/ Y l ��1�` Q �2C A' CHECK if BILLING ADDRESS <br /> FACILITY NAME 1 '^C 1C� Cv� ^ I C)q <br /> SITE ADDRESS 1c��1 l� l 'C� qT/Lvik C4" (j�j"7j4C <br /> Street Number Direction Street Name City- Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) `3-1 J ` �pV�GI C)01(� k S <br /> ) Street Number Street Name <br /> CITY L'I ' STATE CA <br /> ZIP 062-0(,0 <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> (20°i) '�Ct 3 01'1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR J <br /> \ I G`� PeA I„\ ����7 C��� S��l C �!it il CHECK if BILLING ADDRESS <br /> BUSINESS NAME vl v/L 1 PHONE EXT. <br /> Ws 1 ' air l01 S �e\I-eYo. � <br /> HOME or MAILING ADDRESS FAX# <br /> CITY S\��_� J STATE �1� ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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: X n DATE:SC� — °I — <br /> PROPERTY/BUSINESS OWNERq OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANTrknot 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/sp sessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at t11�Z t is <br /> provided to me or my representative. •c��c <br /> TYPE OF SERVICE REQUESTED: -ft6 Fp <br /> COMMENTS: CA.Ct YICAf 0hFq�Tl�jRo <br /> U vv H pFp,OY 4 NAY <br /> NT <br /> ACCEPTED BY: 1 V L W&I , EMPLOYEE#: DATE: <br /> ASSIGNED TO: S S/3 I /i� L EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: SOD� <br /> Fee Amount: I� Amount Pal Payment Date <br /> Payment Type 1 Invoice# Check# Rec '/ed By: <br /> 4&— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />