Laserfiche WebLink
SAN JOAOUNTY ENVIRONMENTAL HEA <br /> ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> a /JJ�A/�/jj SERVICE REQUEST# <br /> OWNER/OPERATOR sly <br /> �`��^l.^c L✓ j�[ot�t � CHECK if BILLIN_ G ADDRESS <br /> FACILITYI 1 NAME 7�k - } 7 Edi <br /> �� .. - !.�✓7� ,tet. Cf'f!lf G'� t 6��-i �,� � <br /> SITE ADDRESS <br /> 7 <br /> C Sbeet Number Direction f �� ` Same �� ,L- �a� <br /> HOME or MAILING ADDRESS (if Different from Site Address) C` Zi Code <br /> CITY Street Number <br /> Street Name <br /> STATE ZIP <br /> PHONE#1 Exr. APN# <br /> ( ) LAND USE APPLICATION# <br /> PHONE#2 Err. <br /> ( ) BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING G_ ADORES <br /> BUSINESS NAME <br /> t�fi�2 It yup PHONE# Ext. <br /> HOME or MAILING ADDRESS <br /> C J� - C��rll�.r Fsv Fax# <br /> CITY 1, 5-) e�/-�s <br /> C'A 1 STATE zip <br /> BILLING ACKNOWLEDGEMENT: I, the undersi edroe <br /> P P or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENT <br /> or activity will be billed to me or my business as identifie is LTH D AR hourly charges associated with this project <br /> I also certify that I have prepared this applicationa <br /> COUNTY Ordinance Codes,Standards,STATE g k to e e e done in accordance wiJ�a11 SAN JOAQUIN <br /> aw _ <br /> APPLICANT'S SIGNATURE: <br /> PROPERTY/BUSINESS OWNER❑ DATE: <br /> OPERATOR/1)4ANAGER ❑ OTHER AUTHORIZED AGEN <br /> IfApp"CANT is not the BILLING PARTY proof of authorization to sign � <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable;I,the is <br /> rroperator of thepropertyTre <br /> above site address, hereby authorize the release of any and all results /si located at the <br /> information to the SAN JOA UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Q , geotechnical data and/or environmental/site assessment <br /> provided to me or my representative. as soon as it is available and at the same time it is <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: e,-e y1 � Cr► � <br /> PAYM <br /> RECEIVE <br /> OCT 2 2 20 <br /> ACCEPTED B SAENOIRONMENT NTy <br /> EMPLOYEE#: <br /> ASSIGNED TO' 4 DATE NT <br /> o <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: A <br /> Fee Amount PIE:Amount Paid <br /> Payment Type J LA S `— PaYment Date `Q 1 "L-2-1 <br /> t/ Invoice# Check# 92-L b 9 Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br /> SR FORM(Golden Rod) <br />