Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE Rh EQUFST% <br /> OWNER/OPERATOR7 r (A/� <br /> i Pt C 1 CHECK If BILLING ADDRESS <br /> FACILITY NAME Jai t p'b J - e (, / J <br /> SITE ADDRESS 7 60 ' a��I o e S� # �, ��C- <br /> Street Number Direction W Street Name !citv Zin Code <br /> HOMES or)M/AILING AAD/D,2ESS�Zltcyot- <br /> f Different from J�Ciitee Address) CA Sr —/7 <br /> 5 LC b b ' C49 C. Street Number Street Name ✓ I <br /> CITY �I, a STATE ZIP <br /> PHONE#1 ( EXT APN# LAND USE APPLICATION# <br /> Obq) 17 yo I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) OCA U <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR {t– CHECK if BILLING ADDRESS <br /> BUSINESS NAME !�/pZP/ _-V D Q PaOQ q 3-701 <br /> 1 2�O EXT. <br /> HOME or MAILING ADDRESS /' /�J� Jff FAX <br /> # <br /> CITY /✓ � STATE C ZIP S <br /> BILLING ACFZ OWLEDGEMENT: 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 /> 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,ST�FALWS. <br /> APPLICANT'S SIGNATURE: DATE: o <br /> PROPERTY/BUSINESS OWNER El"" OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 mation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is proV. ed or <br /> my representative. L <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> C V o✓I cl O f 0 l chi LQ� TyoF gRFh oCh�- <br /> T <br /> �F^'T <br /> ACCEPTED BY: �. `-T EMPLOYEE#: DATE: 3 j <br /> ASSIGNED TO: �-a EMPLOYEE#: DATE: j j <br /> Date Service Completed (if already completed): SERVICE CODE: C, P1 E: Leo-_7 <br /> Fee Amount: 6 j'�``U Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> 07/17/08 <br />