Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 74PMJk&k R�r'+pR*4T x`18 20 SZ 00'&A01q 5 <br /> OWNER/OPERATOR `I <br /> �G.' � ��.�� Qy C UO��/f, CHECK If BILLING ADDRESS 10 <br /> FACILITY NAME ^oCO FFFFR7777��o^"'�", R/STRo <br /> SITEAooREss y/Os Cifie qvE_ STocle�eA/ 9520¢ <br /> Street Number (rection Street Name Cfty Zp Cade <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#t Ext. APN# LAND USE APPLICATION# <br /> (zo9 ) 6-1:76- 6;77-7 01A6260'5) <br /> PHONE#2 Exc BOS DISTRICT.yLOCATION CODE <br /> I ) 6y, `0 .1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> _ ) (, Pt N l � �U '1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE#2Exr. <br /> c -1 l 8-—2'L27 <br /> HOME or MAILING ADDRESS FAX# <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: #11.7/-z 0 <br /> PROPERTY/BUSINESS OWNER' OPERATO /MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILL/NG PAR TP 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. <br /> TYPE OF SERVICE REQUESTED: 4e(,A/ LVf --Z <br /> COMMENTS: e /{GL ..�. ` /V D <br /> OR 2120, <br /> Cat <br /> � HE NrH pEPMENrq try <br /> ACCEPTED BY: / ptt r.4&r o EMPLOYEE M DATE: <br /> ASSIGNEDTO: ohr EMPLOYEE DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P/E: -//Q Z <br /> Fee Amount: * 192 V V I <br /> Amount Pai /V.OD I <br /> Payment Date 6IA <br /> /;Z-U <br /> Payment Type Invoice# Check# /07/ <br /> 17"2_0 Recei ed By: <br /> EHD 48-02-025 - SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />