Laserfiche WebLink
J <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST S�-oK-D`c�2 bz <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> h L�L\\e- �.X) C�' —5f MW <br /> OWNER 1 OPERATOR CHECK if BILLING ADDRESS <br /> V-(ydC&&�' ZJ— -0�- <br /> FACILITY NAME AAALAX7(- k5daNvaAAaA, <br /> SITS Ad ESS 6!.,. <br /> StreetNumber rest Name ti dVe <br /> HOME Of NG D ESS (If Dirent fro to Addr <br /> eLtreet Number Street Name <br /> CITY STATE ZI 3 <br /> PHONE*##1 ExT, APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME P NE# J q'xT <br /> HOMEIr IL DRIES FAx# - L <br /> ( ) <br /> CITY 94� „ STATE C <br /> 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 10AQUIN <br /> COUNTY Ordinance Codes,Standards, STT nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: /0 <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: 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 tl»Asame time it is <br /> provided to me or my representative. A <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 6UY <br /> /�YJM <br /> 1 �� <br /> FNyv i, 00019 <br /> ��, l"" cryo°N,yECO�N <br /> Fpq� 4 <br /> ACCEPTED BY: 1 EMPLOYEE#: � DATE: <br /> ASSIGNED TO: t EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Pr 59; <br /> Fee Amount: qie I Amount Paid OT- Payment Date it <br /> Payment Type Invoice# Checkl5# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br />