Laserfiche WebLink
SAN JOAQUIN t OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1E>21M.7?7-77 <br /> OWNER I OPERATOR <br /> I Ii N G fL C I t/ ��—�16 `N C CHECK If BILLING ADDRESS <br /> FACILITY NAME "1 <br /> IIJNC;ZCI 1 y r, T/0n4 TRGOs <br /> ,SITE ADDRESS ZG�v I _ _ I✓1(�, ��y S—10 C <br /> Street Number Direction J�--��t'� Street Name city Z113 Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) r) I S HAiDow l3 Zaok LN <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> -Ire i t:CA CP 9 336 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (?00) ?As i (- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION ODE <br /> t-1 l�? 00 <br /> CONTRACTOR If SERVICE REQUESTOR <br /> REQUESTOR T <br /> C 1-1 -t r-yl-- <br /> Iz 1 O f CHECK If BILLING ADDRES <br /> BUSINESS NAME PHONE# EXT. <br /> INt11_ '% l' - V r1C It ap u ?JO 4�cto %''1,US <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY M r r l STATE /I ZIP <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 /> 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: / -- DATE: <br /> PROPERTY/BUSINESS OWNER❑ �BIPL <br /> ERATOR/ ANA R OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the LING 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 G <br /> aOAT�t�► RT is provided to me or <br /> my representative. <br /> CENEID <br /> TYPE OF SERVICE REQUESTED: QUID V E N I GLS A/ SP60- / <br /> COMMENTS: N Cil` d i' IN r) C lC S I ?' r� r t8 I <br /> SAN JOp'QUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT, <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: 1 EMPLOYEE M DATE: <br /> Date Service Completed if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type �_ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />