Laserfiche WebLink
0 �► <br /> SAN JOAQUIN COUNTY ENVIRONNIENTAL HEALTH DEPARTIIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# VICE REQUEST# <br /> Z— <br /> OWNER I OPERATOR (% , I CHECK if BILLING AODREss❑ <br /> FAC&M NAME <br /> SITE ADDRESS <br /> 1-2-11-4 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Strut Number Stmet Nam& <br /> CITY STATE zip <br /> PHONE 111 Ext• APN S LAND use APPLICATION 0 <br /> PHONE#2 Est• BOS DISTRICT LOCA CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> RECIUESTOR ` CHECK if BILLING ADDRESS❑ <br /> Ext_ <br /> BUSINESS NAME PHONE 1)U_+6 14) <br /> HOME or MAILING ADDRESS GK-V l t- FAX# <br /> DIC). pJox tQ (164) -�& ,Bit t <br /> CITY I31 STATECA zip Ct <br /> BILLING ACKNOWLEDGENIENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HCALTII 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 he done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards.STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: r DA•rr: Z3'2(JL"3 <br /> 1 <br /> PROPERTY/RUSINESSOWNFR❑ <br /> C <br /> OPERATOR/MANAGER 0 OTHER:♦ltTf10Rt2tat:\GE\'1' <br /> IfAPPm.4.\T is not lite B(LLIAG PARTY.proojof realtori atiou to sigil is regilircd Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 representative. <br /> MT <br /> TYPE OF SERVICE REOuESTEO: p pAYIN <br /> COMMENTS: <br /> �p,R 2 3 209 <br /> SAN JOAQUIN COUNN <br /> ENVIR pEPAR� <br /> 34T <br /> ACCEPTED BY: EMPLOYEE#: 6 DATE: /! <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P f E: <br /> Fee Amount: 'Z , �" ° Amount Paid1 S _ Payment Date 3 Z3 C) <br /> Payment Type 3 invoice# Cheelt f 2 b 0 Received By: <br /> END 48-02.025 C 0 � SR FORM(Golden Rod) <br /> REVISED 11/17!2003 <br />