Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />SERVICE REQUEST # <br />:5ery ce 544' on <br />lTcqcO <br />ACCEPTED BY: alt% <br />OWNER P RA OR <br />` <br />�' <br />V <br />CHECK if BILLING ADDRESS ❑ <br />FACIUTYNAMF { <br />" <br />EMPLOYEE #: •L <br />SITE ADDRESS <br />l� I <br />V Street Number Direction <br />DeNa <br />city Zi Code <br />Ci <br />HOME or AILING ADDRESS (If Different f om Si Address) <br />l q (P <br />1 E: Z3 O{o <br />11 v)S Ldn S <br />tr <br />3 (o (o , 0 p <br />treet Name <br />CITY �n O <br />STATE NC <br />iP 7cG S <br />P <br />(fiNE#1 <br />b ► <br />a <br />A PN # <br />0a -5\c® �q <br />#z <br />LAND USE APPLICATION <br />PHONE #2 <br />l 1 <br />ExT <br />BOS DIST ICT <br />11 <br />LOCATION CODE <br />99 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR-7-B <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # ExT. <br />HOME or MAILING ADDRESS <br />FAX# <br />( 1 <br />CITY STATE 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE d FEDERAL laws. <br />APPLICANT'S SIGNATURE: C ' 3 DATE: 31411 <br />t 1 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENTI� / I e C C oo � <br />If APPLICANT 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 representative. ... wvMFNT <br />TYPE OF SERVICE REQUESTED: <br />T- <br />EIVED <br />COMMENTS: <br />M n IR n <br />• <br />s4t4 OAROMENum OA- <br />HEALTH DEpApTMENT <br />ACCEPTED BY: alt% <br />EMPLOYEE #: (t%('�J <br />DATE: �j 124 t <br />ASSIGNED TO: Z i' <br />EMPLOYEE #: •L <br />DATE: <br />Date Service Completed (6 already completed): <br />SERVICE CODE: <br />l q (P <br />1 E: Z3 O{o <br />Fee Amount: 1p 31, % •0 <br />Amount Paid <br />3 (o (o , 0 p <br />Payment Date ' <br />Payment Type <br />Invoice # <br />Check # &2- — <br />Received By <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />