Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 6rAS STP-Tfo-I 6$iso <br /> OWNER/OPERATOR <br /> �F'So/2r� Je['P1„11AIC/ ANIkR/<g cCHECK If BILLING ADDRESS❑ <br /> FACRrrY NAME <br /> T�o/zolusA (og/sv <br /> SREADDRESS /3975- EA57- /7Yt✓r' 88 Lp('J(_•Po/2/) x/5237 <br /> Street Num r eros Ns e Cmay ZIPCoe <br /> HDME Or MAILING ADDRESS (If Different from Site Address) <br /> /9/00 P'/at.:; <br /> alreat Numher , <br /> CITY S/}./V/ AA/7Z)k/(0 STATE ZIP <br /> CA 7g2S- <br /> PHONE#1E�*• APN N LAND USE APPLICATION a <br /> ( PT) 687 a-7g3 <br /> PHONEY En. SOS DISTRICT LOCATION CODE <br /> I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEsioa <br /> s4Hno140 UH.4ojIt:-H/ CHECK I}@RLINGADDRESS <br /> � <br /> BUSINESS NAME pHpNE# En. <br /> a S��ll1 rnll=�er✓cj r. ai 0 -g3oo <br /> HOME Or MAILING ADDRESS26Y-'S 6 AA/LD Cyn/ P-0 FAN# <br /> G TT (G 61 ) iso - 9333 <br /> CITY 0n104 CQot'-IpL�(, STATE ZIPgt3 .a-7 <br /> C4 , <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTFI DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that I have prepared this application and that t1hrworrtolic performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and WS.- <br /> APPLICANT'S SIGNATURE: DATE: a' <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/f19ANAGER ❑ OTHER AUTHORI2,F.DACr.NT <br /> fAPPLIC,INTis not the BILLING PARTY.proof of authorization to sign is required True <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, t,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any Rnd all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL 1-1EAurii Diil'ARTMEN'I'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: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNE'O TO: EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />