Laserfiche WebLink
SAN.TOA N COUNTY ENVIRONMENTAL HEAL DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or P11roperty( / FACILITY ID# / SERVICE REQUEST# <br /> Cow�w,�I C �a.\ S�rV Ca 5����c� (_Q C) 1—O 1 <br /> OWNER/OPERATOR <br /> 6F1Ae c c CHECK If BILLING ADDRESS 13 <br /> FACILITY NAME n n 2 C j0�t\ 6 O z O <br /> SITE ADDRESS / ( / <br /> Yp� Q m�-�'2 l�ve n Q� 1'n �r`fe c�c. qs 3 3 (oStreet Number IrectloT s a I Zip Code <br /> HOME Of MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN 0 LAND USE APPLICATION <br /> ( ) <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Vh O�.�2 S G-''`� Ccs 9 a✓�-�-) <br /> BUSINESS NAME S Q �y� c ^` PHONE# E.T. <br /> Z�C- . s/o (PIc4 g3 go <br /> HOME Or MAILING ADDRESSFAX# <br /> 2-G co <<1'�o-w`s 5-t • (5-10) (91 - g 3 9 ca <br /> CITY S O-V% L Q O—�f O C � STATE C '- ZIP 9 g S--2 <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 <br /> or 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 TE and FEDERAL Imp. <br /> APPLICANT'S SIGNATURE: 1/, DATE: — Y — 08 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGE ❑ OTHER AUTHORIZED AGENT <br /> If APPLlCANT 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site 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 %resentative. <br /> TYPE OF SERVICE REQ D: YMENT <br /> COMMENTS: REC <br /> JUN 4 2008 GAA <br /> SAN JOAQUIN COUN-Ty 4 * <br /> ENVIRONPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: V EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: Iq P 1 E: <br /> Fee Amount: D Amount Paid v Payment Date LJ(Q <br /> t <br /> Payment Type ✓ Invoice# Check# 15—If I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />