Laserfiche WebLink
SAN JOAQUI) OUNTY ENVIRONMENTAL HEALTHJEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Aff Cc 5F1008 Its 3 <br /> OWNER/OPERATORCHECK If BILLING ADDRESS❑ <br /> Is <br /> FACILITY NAME -e t C <br /> SITE ADDRESS lW` <br /> .120 Sheet Dir,ction ' �etNNaa e city <br /> HOME or MAILING ADDRESS M Different from Site Address) �� <br /> Z k—� 1 OZ 'e'� Street Number �� � Name <br /> " <br /> CITY STATE ZIP 2 <br /> CSC C14ok— <br /> PHONE#1 E7-7 PN# LAND USE APPLICATION# <br /> (2,M ) (Q l2.—0430 <br /> PHONE#Z ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOtK,', ` <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME -J PHONE# _ v _ `ExT. <br /> HOME or MAILING ADDRESS FAX# l <br /> tc5-2-XA <br /> CITY m2w CA <br /> STATE ZIP G] <br /> BILLINA KN EME : 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 JoAQum <br /> COUNTY Ordinance Codes,Standards, TE and FEDE la s. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER, OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tate <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 atift same time it is <br /> provided to me or my representative. M <br /> TYPE OF SERVICE REQUESTED: bQL A+ G)rlu( � �` P <br /> COMMENTS: <br /> mow,, 3 ?0 <br /> 19 <br /> HEALTH�EPMFNT�)Y <br /> gRTj y�NT <br /> ACCEPTED BY: Sjh04-7-t EMPLOYEE#: 6;6-5(a DATE: <br /> ASSIGNED TO: EMPLOYEE M. DATE: ` <br /> Date Service Completed (if already completed): SERME CODE: (5(0 ( PIE: / 3 <br /> Fee Amount: 152,4U Amount Paid /So2.vd Payment Date 17 <br /> Payment Type C Invoice# Check# ` 1 C Recei d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />