Laserfiche WebLink
i'ARTMENT <br /> I <br /> SAN .�UAQUIN C N`i'Y NViRONMLN'1'AL HEAL'i'il <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 2Oo 3,17 <br /> OWNER/OPERATOR C <br /> StFm atzs6nJ CHECKH BILLING ADDRESS <br /> FACtuTy NAME <br /> SITE ADDRESS c15'8/ 5.-A.� P40jl Tr g� 5 �� q� f Z <br /> 0 <br /> Street Number Direction Street Name Cit 7i Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) /L'9&-L/, 50' 44 �^ <br /> Street Number s1rect Name t`�Y <br /> CITY � �.1 STATECAZIP p� _ <br /> PHONE#1 s Err. APN# ©G Z LAND USE APPLICATION# <br /> Cl I <br /> (709 ) � .. X70 ° �--0 �6 <br /> PHONE#2E%T. BO5 D1STRkCT LOCATION CODE <br /> ( ) ,?,57/ z _711 <br /> CONTRACTOR/ SERVICE REQUESTOR l <br /> REQUESTOR ` , <br /> n(` ! CHECK if BILLING ADDRESS�Y <br /> BUSINESS NAME Trr t � PHONE# �� Exr. ' <br /> �F 66/3 <br /> E MAILING ADDRESS FAX# <br /> STATE ZIP S 7 it 1 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of saute, <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 nye or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be perfor will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. �J <br /> APPLICANT'S SIGNATURE: DATE: �J J <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER © OTIirm AUTI[ORYLCI)AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of autliorization to sign is required Title <br /> AUTHORIZATION TO REI_,EASE 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 environmentallsite 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: ,j dl Lr��T/3/s3i G.T EC��V Ep {I <br /> COMMENTS: <br /> JUL <br /> A'N jokau,ta cout4v <br /> Pi�>3tic <br /> APPROVED BY: EMPLOYEE#: cc)5 1 r DATE: <br /> ASSIGNED TO: M// /m EMPLOYEE#: J��[ ({ DATE: f/ <br /> Date Service Completed (if already completed): SERVICE CODE: P/E; <br /> Fee Amount: �� .-- Amount Paid 2 1_7 j� Payment Date 03 <br /> Payment Type ✓ invoice# Check# L Received By: � <br /> 4 <br /> EHDSERVICE REQUEST FORM <br /> REVISEDSED 6-5.-5-02 <br />