Laserfiche WebLink
SAN JOAQUIN OUNTY ENVIRONMENTAL HEALTH DOTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />T <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER / OPE <br />TOR <br />4�yl LJ e-vidiCHECK <br />CHECK if BILLING ADDRESS <br />FAgLITY NAME <br />RA -Is <br />J <br />PHONE# <br />2pq) <br />SITE ADDRESS <br />��C7V <br />$ Number <br />Di <br />S!.Ow <br />• n <br />t i <CGi-(r11e/iTzq R <br />Street Na <br />C3 LO <br />)Z19 <br />C'ty <br />Zip Code <br />HOME Or MAILING ADDRESS (if Different from Site Address) <br />Scree Numbsr <br />CITY <br />64 <br />Street Name <br />CITY <br />Fee Amount: <br />00 <br />STATE ZIP <br />PHONE #1 <br />( ) <br />Payment Dat f fit, O " <br />Payment Type <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />Check # ; F'12'-7 <br />EKT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />COMMENTS: <br />If BILLING ADDRESS <br />4�yl LJ e-vidiCHECK <br />ACCEPTED B <br />__P_ <br />BUSINESS NAME <br />-�OrtiS cor�1 f t l <br />a1 n C. <br />PHONE# <br />2pq) <br />SI(7-q3 10 106 <br />HOME or MAILING ADDRESS <br />X , L s <br />FAX # <br />EMPLOYEE #: 3�o <br />C3 LO <br />DATE: <br />21 Or <br />('2-&T) <br />S 7-1312- <br />- 3)2CITY <br />CITY <br />64 <br />STATE <br />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 <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 applicationend that the work tp be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST TE FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT 1 L�� Pry S . <br />IfAPPLiCANT is not the BmLDyG 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/si <br />stn <br />t <br />�eassessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available "-j - e time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: U 5 T- ac+,v 6' 4- <br />COMMENTS: <br />t, <br />APR 2 , <br />SAN JOAQUIN COUNTY <br />HEALTH DEPARTMEW <br />ACCEPTED B <br />EMPLOYEE #: q (0 9 <br />DATE: ® C/ I r OS <br />! <br />ASSIGNED TO: <br />X , L s <br />EMPLOYEE #: 3�o <br />DATE: <br />21 Or <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />l g d <br />P f E: o2 3 pg <br />Fee Amount: <br />00 <br />Amount Paid <br />42-11. D V <br />Payment Dat f fit, O " <br />Payment Type <br />Invoice # <br />Check # ; F'12'-7 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 Of <br />