Laserfiche WebLink
• SAN JOAQUI*UNTY ENVIRONMENTAL HEALTI PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 C -59'`i S <br /> OWNER/OPERATOR <br /> Ir J A 6-L)/ ) CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME /`/ `(J /( <br /> &4P-Ja4&L1/A) � . Puguc- WZAksC�RPaRg-f i��1 ,164" <br /> SITE ADDRESS �/�Z��-� Tq's-.-26f <br /> I lD <br /> Street Number Direction Street Name CI Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PJIAStreet Number rl Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> $:f ) #6?- 3 3 79' /ss- 14a - o <br /> PHONE R EXT. BOS DISTRICT LOCATION CODE <br /> l ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR J 61r si-e �/Q M <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Q^ ,r }yte n^ 1 C. <br /> PHONE# EXT. <br /> T l�Z� <br /> HOME or MAILING ADDRESS FAX# <br /> .2-3 7a M 10 C�k ef-L 6 S ) 361 <br /> CITY 40,01 <br /> 01 STATE ct ZIP qrA Oto <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 ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT A a& S J <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the pr466a�at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmen eIMEDment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and[)E f e faT it is <br /> provided to me or my representative. S�_ (Y� ��u1t(�jJy <br /> ENVIRONMENTAL TY <br /> TYPE OF SERVICE REQUESTED: <br /> `e A40/JC fOA W/IQ./A J& P,6 M HEALTH <br /> COMMENTS: <br /> FR0.4-1 S7 OCI 4W r V 0 C S6N.04 -to 7"Gs - 3S0 Czx;?' �- vNi t`- <br /> ACCEPTED BY: LD(.{V c—it ta-4 EMPLOYEE M L& DATE: �I <br /> ASSIGNED TO: EMPLOYEE M c� C f��{ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: / q PIE: <br /> Z3 <br /> Fee Amount: 3 `E S'. Amount PaidL(1 S Payment Date 1 2 W 6 <br /> Payment Type Invoice# Check# '� 3y 1�_ 31S lfb I Received By: t4Z5--"' <br /> e..Q�. 30,asp <br /> EHD 48-02-025 3� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />