Laserfiche WebLink
05/15/2008 15:23 12095453848 OFFICE PAGE 01/01 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Tvoe of Business or Property FACILITY ID If <br />�8ar�w� 2-2(9 <br />SERVICE REQUEST # <br />52oo5-4ZS� <br />OWNER/OPERATOR <br />CHECK if 91LUNG ADbRE55 ❑ <br />FACILITY NA" <br />CITY <br />StTEADDRESs s � ( �G1E.,i�t4s/,1%�cr4 PL vc OIV- <br />elre¢t NumMr Duectio e!m o e <br />ri Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />SqN JO 2 <br />- <br />afrvet NumbBr <br />N ENVi y oU/ly c <br />EAUN 04, <br />Ste N mo <br />CIN <br />SIT% YIP <br />PHONE 91 R"T <br />C1 V7 <br />EPN# <br />3leo,a <br />LAND USEAPPLICATION3 <br />( ) <br />(og- <br />PHONE #2 Ex.. <br />SOS DIBTRIcr� <br />LOCATION CODE <br />CIINTRACTOR / SERVICE REOUESTOR <br />IZEQUESTOR ,� A! CNECKfFBILLING ADDRESS El <br />u/�«./�� <br />BUS INESS NAME h <br />_ <br />HOME or MmunG ADDRESS <br />( # <br />CITY <br />1 STATE ZP <br />BILLING ACTSOWLEDGEMANT: 1, the Undersigned property or business owner, operator or authorized Rgeet of same, <br />aclmowledge that all Site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to we or my business as identified on this form. <br />I also certify that I have prepared this applica ' and that the work lobe perforated will be done in accordance with all SAN JOAQUiN <br />COUNTY Ordinance Codes, Standards, STA d PL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER❑ 09 TOR/MAN Ll OTREFAUTNORIEEDACENriPK %�8I P\Rr <br />If APPLICANT is not the ILLI proof of authorization to sign fs reyalred Title <br />AUTHORIZATION TO RELEASE INPO ATION; When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorite the release of any and all results, geotechnical data and/or environmentaUsite assessment. <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RS Soon as it is available and at the same time It is <br />..mrive v',,,eJ—- r'.n c1_G_'r?l=ek7 pgYR_ <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REMSED 11117/2003 <br />OT <br />/. <br />vry <br />TYPE OF SERVICE REQUESTED: <br />COaMENTa: <br />AY j 5 <br />SqN JO 2 <br />- <br />N ENVi y oU/ly c <br />EAUN 04, <br />p: ME <br />ACCEPTED BY: O C_C ✓ c` t �-'T <br />EMPLOYEE#: 0 3 L( <br />DATA: S- _T/0 <br />ASSIGNEDTO: �1 C,LgS <br />EMPLOYEE#: d t-E(,�� <br />DATE: _5- <br />SDate <br />DateService Completed (If already completed): <br />SERVICE CODE: o(, <br />P I E�j e,03 <br />Fen Amount: .9g'.� <br />Amount Paid <br />8 <br />Payment Date <br />Payment Type <br />Invoice # <br />Check# 3 <br />Received By: Wr� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REMSED 11117/2003 <br />OT <br />/. <br />vry <br />