Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FAt�D��5��1 5Q � ^ S <br /> OWNER/ OPERATOR,/' ^^^iii <br /> CHECK if BILLING ADDRESSO <br /> FACILITY NAME <br /> SITE ADDRESS J�;��+ `• f <br /> I�p51 tree Number Direction !"� I Sfreeme Zi Code <br /> HOME or MAA� SILIN(3 ADDRESS If Different from Site Address) 1/ <br /> 3V 1 Ma J �&tr�t umber Street Name <br /> CITY � STATE ZIP <br /> &V4 <br /> PHONE#t ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> } <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUE5TDR I1 � <br /> I�r _ Il,� CHECK if BILLING ADDRESS <br /> BUSINESS NAME V`N ►� PHONE EXT. <br /> S d;� ca a - Gr53 - b <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 5 I SM <br /> ZIP S2! <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, TATE an DERAL law <br /> APPLICANT'S SIGNATURE: DATE: 12-- .)-j— 2-DLO <br /> PROPERTY/BUSINESS OWNER OPE T /MANAG IihOTHER AUTHORIZED AGENT❑ <br /> IfAPPLICRN i,not the BIL cPARTY,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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: A <br /> Dec 2 9 ZO2�1 <br /> y��R�NM CpU� <br /> Typ��Nr,� 1r <br /> ACCEPTED BY: �J y�/},C�n/t /ti EMPLOYEE#: DATE: ?j <br /> ASSIGNED TO: II <br /> Mon <br /> LSLS EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 [ PIE, <br /> Fee Amount: 0 iJ Amount Paid Payment Date <br /> Payment Type Invoice# Check#i• �2� Received By. <br /> EHD 48-02-025SR FORM(Golden Rod) <br /> REVISED 11/17/2003f�-A2-131 <br />