Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
SAN JOACtuIN COUNTY ENVIRONMENTAL HEALTH JEPARTMENT <br />SERVICE REQUEST <br />Typg.of Businss or Property <br /> <br />sk-00C K---- <br /> <br />1 (/ <br />FACILITY ID # <br />r ,g., t/k.; , <br />SERVICE REQUEST # <br />C:\ ,;- a 7S 0 0 <br />OWNER P CIERATOR - , PO CC CHECK if I <br />/ <br />BILLING ADDRESS <br />FACILITY NAME / <br />'POS-e- (-1i YN- fl ; <br />SITE ADDRESS <br />50 ni**5.1..Pr- Street Number <br />4) <br />Direction <br />1 (fi-, i_c °4 C <br />Street Name <br />Sek0C--,14-ttsle-N <br />City <br />Cr <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />112 —i litlWiAtiat5e Street Number <br />4V"- !Owl ..D.I. <br />Street Name ) <br />CITY STAT ZIP <br />b ( 4—c--T-1'-\ 9 ---.,_;z / s- . <br />tt ft <br />PHONE #1 EXT. <br />(2O1) <br />APN # I LAND USE APPLICATION # <br />PHONE #2 EXT. <br /> <br />..r e, • <br />(2J? ;;P-ii <br />SOS DISTRICT <br />c, ()-- <br />LOCATION CODE <br />61(1 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR c hrk s ...h ric,„..._ ,---?1 al c. fri 4.c ( <br />CHECK if BILLING ADDRESS 4, <br />BUSINESS BUSINESS NAME 'OS C 1/4- vl /r1 lc PHONE # <br />C -6 '—. <br />EXT. EXT. <br />HOME or MAILING ADDRESS 0, 1 Prb edot,1 FAX # <br />( ) <br />CITY 5 tbco-Dv \ STATE CA ZIP C/t5— 4 c <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 erformed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standard TE0nd FED RALc4OWS. <br />DATE: <br />OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <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/si <br />TY <br />assessment information ih4to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same latmr„avided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: rocci ,) e h c r e I I, , p .e ( 1-7 6 , ) 4.4.1 <br />COMMENTS: <br />L 1 c., l'- lo ;,-7c-":7 Q6 & <br />.) r Lf 4 f it <br />1 40/7 8A/v J04 ,, <br />Ht....ivviR ts,A.T.fy couN , <br />.7. <br />ACCEPTED BY:C.--;:; te—c( EMPLOYEE #: DATE: ) i 2._ i . i 7 <br />ASSIGNED TO: k 11/4.)0 not EMPLOYEE #: DATE: i i - 17 <br />Date Service Completed (ii already completed): SERVICE CODE: 0 i , P/E: <br />Fee Amount: 1 ,..--y2.51.-) Amount Pm 7G—r), 0 0 Payment Date 7/21n7 <br />Payment Type Invoice # Check # Received By: <br />APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER.- <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08