Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ PERA'TUR n <br /> K —CAN <br /> rl(.! /� CHECK If BILLING ADDRESS <br /> ACIUTY NAME jr w 1�-(( -)/v v <br /> T$ITEIDDRESSAve,. 1146m feoa "15 6 <br /> Street Number Direction Str¢¢t Name Cit Zip Code <br /> OME Or MAILING ADDRESS,"(If Different from Site Address) 1/�(,� QQQ <br /> _l <br /> Street Number Street Name <br /> :CtTYY <br /> TATE IP <br /> -- �Oc(��o 1'.5 D <br /> fiPHONE'#1j EST' APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BIDS DISTRICT LOCATION CODE <br /> (ZD'I ) q j, g ;t g <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> ,rREQUESTOR-y <br /> IWO CHECK If BILLING ADDRESS <br /> ]BUSINESS NAME ILLS ,Y VH NE 'r <br /> _ fCPD �8 <br /> `TbimE rMAILING ADDRS �� FAx <br /> S <br /> CITY"— /I1_ STATE C/1 ZIP R� <br /> 1 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 Coder,Standards, S ATE and FEDERAL laws. <br /> A PLICANT'S_SIGNATURE:P <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> I,fAPPLICANT 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. f1 ^ P <br /> TYPE OF SERVICE REQUESTED: M UU �jv r` '��t Cy <br /> COMMENTS: Alop <br /> Owu�Os1,vgp �o <br /> EIyIy QbGy <br /> N��OFPMENTgC 7Y <br /> �FNT <br /> ACCEPTED BY: (N MO V10 EMPLOYEE#: DATE: <br /> ASSIGNED TO: Q. f-'AIA LMAX EMPLOYEE#: DATE: (�(/ <br /> Date Service Comp ted (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: I�2 Amount Paid /5' Qb Payment Date ZD <br /> Payment Type 1�t2 Invoice# Check# I/I G9 833(ls ReceivedtBy: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED II/17/2003 �,n ��1 <br /> �uq <br />