Laserfiche WebLink
SAN JOAQ91 COUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> PA-1 L 5A1,0 Al r� 2.W 1 <br /> OWNER/OPERATOR <br /> ®A)C-r "fJ CHECK if BILLING ADDRESS <br /> FACILITY NAME I A/- -ro"C# MiISS S ) q� �/g <br /> SITE ADDRESS ' 130 4fG ', f � Pd, J-(1 k, O P /53 30 <br /> Street Number Direction �o� Q S r�t4N�e t` Ci ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> t ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR #®/�/.1 <br /> 6r- 14 4A) CHECK if BILLING ADDRESS® <br /> BUSINESS NAME -(A u -r0U(.f 77 SI /f PHOE# — . <br /> ( 56 <br /> HOME or MAILING ADDRESS �V G FAX# <br /> MAP-co <br /> ( ) <br /> CITY) STATE i1L ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersignied 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 or <br /> 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 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: 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 Title <br /> AUTHORIZATION TO RELEASE INFORMATION: Wh6n applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and qlI results,geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: to <br /> COMMENTS: � I <br /> vz h r- c�12C1C !O V 2 6 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: kA ('', S' EMPLOYEE#: DATE: `1 -7 <br /> Date Service Completed (if already completed): SERVICE CODE: 5 P/E: <br /> Fee Amount: -78 Amourit Paid7 Payment Date I - 7- <br /> Payment Type �C Invoice# Check# Received By: <br /> Y <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> i <br />