Laserfiche WebLink
SAN JOAQUIN COUNTI' ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> 7Type of Business or Property =ID# SERVICE REQUEST# <br /> OWNER/OPERATOR l� Lt <br /> if BILLING ADDRESS El I+L r tip-r� <br /> FACILITY NAME <br /> v � _ <br /> SITE ADDRESS ,3 S / '� <br /> l �� I(c1 e-C„ <br /> Street Number Direction tree/Name City ! Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1 6N L f I Street Number Street Name <br /> CITY �� $TATE � ZIP <br /> l C yrs <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> ( ) Y30 ' - 3 10 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ^ ^ ' \ Lf y CHECK if BILLING ADDRESSO <br /> BUSINESS NAME Y1 S. ` PHONE# Ext. <br /> 1� QvL1'nS 4 c70 <br /> HOME Or MAILING ADDRESS FAX# <br /> CIT, Ct <br /> E ZIP ya <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: F 0(,rG1 c-,,., ' ,L- �C DATE: o <br /> 6 A <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorizatiQn 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 <br /> and <br /> Ythe <br /> time it is <br /> provided to me or my representative. an <br /> _ �J ry <br /> TYPE OF SERVICE REQUESTED: �' u <br /> COMMENTS: <br /> SAENVVIRONME TNIEtVT <br /> HEAL"i DEPAR <br /> ACCEPTED BY: EMPLOYEE#: r�4-� DATE: O r 2�_ <br /> ASSIGNED TO: K` ou- :�dEMPLOYEE#: /„ u DATE: (/O_ <br /> Date Service Completed (if already completed): SERVICE CODE: W* -j'2Z PIE: <br /> Fee Amount: 00 Amount Paid Payment Date U Z>f I <br /> Payment Type Invoice# Check# g(z Received By: <br /> EHD 48-02-025 t A V,9 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />