Laserfiche WebLink
SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (�oo-7a� I <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Cel,Cc1r Q�CtS <br /> SITE ADDRESS --3%q <br /> IC) l 1 S.)vta1 D�erM�V1�t�tby� ��;Jct Tr<<��7/ C{S <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EY T, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ki c,,v^Uvy\S I v,\ ���� K4, CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ext. <br /> 2 <br /> HOME Or MAILING ADDRESS FAX# <br /> �2C7 <br /> CITYSTATF ZIP /� <br /> 'CUs lc�C r `t ? <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 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: DAT —ZU <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT// L C eir,^,'e r <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. ip <br /> TYPE OF SERVICE REQUESTED: C R <br /> Qi <br /> COMMENTS: <br /> ouAV 15 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: TG S J O O u //S EMPLOYEE#: DATE: '5 C�l�/T1 <br /> Date Service Completed (if already completed): SERVICE CODE: Z Z PIE: <br /> Fee Amount: uU Amount Pai ;Z,�,(f),tJ� Payment Date <br /> Payment Type /,i Invoice# Check# �a�/ c�q Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />