Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 7 <br /> aS 1 <br /> OWNER/OPERATOR <br /> 7 J�C CHECK If BILLING ADDRESS <br /> FA LITY E t �y J <br /> SITE ADDRESS sffv_-� <br /> Street Number Direction // Street Name City Ap Code <br /> HE Or M�INGDDRESS 1If Different from Site Address) <br /> 1 // Street Number Street Name <br /> I � STATE ZIP 5�a <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> Iq��► ln3 -�'776 3z - <br /> PHONE#2 EXT. BOS DISTRICT LOCATI ODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> Rrnl ST�� <br /> CHECK If BILLING ADDRESS <br /> B SINE N E PHQNEa r7�F ExT* <br /> Al <br /> f�., ��I J� Go <br /> /HOME or M/AI Al R S / !J G/G� Tr DO (76 ) T 01 S <br /> CITY STATE 64 ZIP 76-0 <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 w k to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S AT and FEDERAL la s. G <br /> APPLICANT'S SIGNATURE: DATE: 6 A2 Q a <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AI THORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is require 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 represen 've. L/ ,ST Ta2�'F— ( T — <br /> TYPE OF SERVICE REQUESTED: JJALe= PAYMENT <br /> COMMENTS: HtULIVtU <br /> JUN 2 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPART <br /> ACCEPTED BY: U t�J EMPLOYEE#: t)_32 DATE: 2 <br /> ASSIGNED TO: / EMPLOYEE#: 2LF l �, DATE: <br /> LF <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E:'Z�O� <br /> Fee Amount: acl bu,�ice <br /> Amount Paid Uv Payment Date /� 4 <br /> Payment Type �� Check# S!1 O Z Received By: Uw`0� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />