Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME/ <br />FACILITY ID # <br />SERVICE REQUEST # <br />F��#U <br />CITY! j1/ STATE `n ZIP sa is— <br />(001575' <br />SN,/ <br />OWNER / OPE TOR <br />L t � ri _I � <br />o n a Cl ��11, lC., <br />I i ` { <br />rt. l <br /><1/Y <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />tU <br />/14R0 COU <br />SITE ADDRESS (`i 90I <br />ACCEPTED BY: T—�G� <br />l� <br />La „ ,�' 16- <br />EMPLOYEE #: <br />DATE: 6 of % ENT <br />C� ��s <br />_l <br />Street Number <br />Direction <br />DATE: �,/Gj d �/ <br />StrevetNomaame <br />Cit <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />(p o 55C <br />Ct rnt Ga- e &u %-i- <br />q <br />Payment Type <br />Street Number <br />Check # �Zg <br />Street Name <br />CITYr <br />5�c -IiC—J% ) <br />$TATE ZIP <br />/ <br />PHONE #1EXT. <br />(209) 14 q0 - r-� vel7 <br />APN # <br />l o! ^ a80 -01 a - 00o <br />LAND USE APPLICATION # <br />PHONE #2 / �� _ oZ9 EXT. <br />( 9) Cly s <br />BOS DISTRICT <br />LOCATION CODECDE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR / n <br />I / / d n s CHECK if BILLING ADDRESS <br />(/` <br />BUSINESS NAME/ <br />- 2 a EXT' <br />PHONE # , /� 05T <br />Y" J !J <br />HOME Or MAILING ADDRESS <br />0 G ar n -( na--, Cau r-4- <br />F��#U <br />CITY! j1/ STATE `n ZIP sa is— <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards,S'I'A'I'E and Dki AL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPER'T'Y / BUSINESS OWNERN OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />/f APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: 'I I ' 1 Ij Gi L i l) �' arc) /I/ ! 'f !la: Lo(.'9 I n� S fV d v 2-V i, i -J PAVAI_ <br />COMMENTS: AW heog 4 N z) at d ofieSSt" S.'W <br />14$c� W�' Lune <br />OCirn1461 <br />�� <br />JUI� ®9 <br />(001575' <br />SN,/ <br /><1/Y <br />tU <br />/14R0 COU <br />Np Al <br />ACCEPTED BY: T—�G� <br />EMPLOYEE #: <br />DATE: 6 of % ENT <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: �,/Gj d �/ <br />Date Service Completed (if already completed): <br />SERVICE CODE: $ 3 <br />P /E: <br />Fee Amount: .j <br />Amount Paid 100 C/ 2) <br />Payment Date <br />q <br />Payment Type <br />Invoice # <br />Check # �Zg <br />Received By: <br />LWA <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />