Laserfiche WebLink
SAN JOAQUL ' AUNTY ENVIRONMENTAL HEALTu DEPARTMENT <br />SERVICE REQUEST <br />Type: of Businesor <br />Pro erty <br />V <br />PHONE# E'. <br />) <br />HOME or MAILING ADDRESS <br />FACILITY ID # <br />II b Z/ <br />SERVICE REQUEST # <br />sena&osoy <br />OWNER I OPERATOR <br />1 -^ <br />W <br />15 <br />�O ' <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />Lk CA I O-✓\ <br />�t� <br />N"✓ l"1 <br />SITE ADDRESS <br />590 <br />iJ <br />Iq <br />(,IyLI`trri <br />V�� <br />f- <br />DATE: _ I IQ <br />4x-337 <br />Street Number <br />Direction <br />DATE: <br />StreetName <br />Cit <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Fee Amount: <br />Fee <br />Amount Paid <br />is x-30 C) <br />Payment Date -1 1 S <br />Payment Type <br />Invoice # <br />Sheet Number <br />Street Name <br />CITY <br />STATE <br />zip <br />PHONE#1 <br />EXT. <br />APN# <br />LAND USE APPLICATION# <br />PHONE#2 <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR QJA WAf''�L•' CHECK if BILLING ADDRESS <br />BUSINESS NAME �.aI <br />"/ N <br />PHONE# E'. <br />) <br />HOME or MAILING ADDRESS <br />FAX# <br />CITY r "-ro STATE C—.4c zIP q S-3-3 <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 projector <br />activity will be billed to me or my business as identified on this form. <br />I also certify that t 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:y l Cv( U" -t <J, Ca vv . -ifJ� DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR /MANAGER ❑ OTHER AUTHORI7ED AGENT ❑ <br />/f 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 />intion to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />P, d -R me ot my representative. <br />TYPE OF SERVICE REQUESTED: <br />Nj <br />CDMMLNTSI <br />ILI <br />2010 <br />15 <br />ve <br />L <br />H�'l'TM <br />ACCEPTED BY: <br />EMPLOYEE #: <br />f- <br />DATE: _ I IQ <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if alrea4 completed): <br />SERVICE CODE: <br />�.Z <br />PIE: -3('002-- <br />Fee Amount: <br />Fee <br />Amount Paid <br />is x-30 C) <br />Payment Date -1 1 S <br />Payment Type <br />Invoice # <br />Check # I D l `j D q-0 <br />I Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />