Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> SR003 '1- �5 `7 <br /> ' OWNERI OPERATOR , I <br /> •AoDness❑ <br /> FACILITY NAME <br /> ' SITE ADDRESS Ig4g3 E Mehrfeb C Crrleilff' q��+z-7 <br /> Sind Numaer Dlreetlon SIrNl Name 11 ZipCode <br /> ' HOME Of MAILING ADDRESS (If Different from Site Address) 9 <br /> S 4f Slreel Number SIeal N S <br /> CITY STATE ZIP (Su <br /> ' PHONE III EeL APN# LAND USE APPLICATION# v- <br /> PHONE 01 E.". BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> ' REQUESTORA 6� n r 1 CHECK If BILLING ADORES$❑ � <br /> BUSINESS NAME N41 PHONE# E"'' ! _ <br /> aol S 3 7 <br /> ' HOME Or MAILING ADDRESS A FAX ) <br /> CITY N STATE 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 ENVOtONMENT'AL HEALTH Dr.PARiTa(iN'r hourly charges associated with this project or <br /> activity will be billed to me or my business as identified ort 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 Cordes,Slnndards,STATE and FrOci t.law S <br /> APPLICANT'S SIGNATURE: ` DATE: 7-✓�' 03 <br /> PROPERTY I BU[INP9SOWNr.R❑ OPERATOR/MANAGEa ❑ OTHER AuTRoRI?PD AGENT 11 <br /> If APPLICANT is not the BILLING Pd RTC proof of RitilioriZe(on to vigil is regeiired Title <br /> ' AUTHORIZATION TO RELEASE. INrORMATION: When applicable, 1, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnicDl data and/or envimnmentatisite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT as soon as it is available and at the some time it is <br /> ' provided to me or my representative. ENS <br /> TYPE OF SERVICE REQUESTED: <br /> CORWENTS: <br /> mar- <br /> 1 <br /> EN`ARONMIxQi <br /> APPROVED eY: EMPLOYEE#: Z7Jr 2 �� 03 <br /> ASSIGNED TO: a EMPLOYEE#: �3wv6 DATE: ( +d 3 <br /> Date Service Completed IV acro tdy completed): SERVICE CODE: �b PIE: Z ti 2 <br /> ' Fee Amount: Amount Paid Payment Date -713 3 <br /> Payment Type Invoice# Check# 3 G Received By: � <br /> ' EHD 4801.025 SERVICE REQUEST FORM <br /> RFVMf-D 0-5-02 <br />