Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> g Ealumou <br /> OWNER/OPERAT R <br /> ' V/ V`t` (I t /r U f4 �` Toyy Q CHECK If BILLING ADDRESS <br /> FACILITY NAME J�LII V � \ ✓ 'SV h��� <br /> SITE DRESS Q /���*/^''-'���t� G'C� <br /> �� Street Number Direction Street Name w--� Cit ZI Code <br /> HOME Or MAILING ADD ESji S (If gjfferent from Site Address) <br /> =� Slraet Number Street Name <br /> CITU STATE OW ZIP /]/ ZO <br /> PHO. t E"T APN# LAND USE APPLICATION# 1/( J <br /> P ON Z I ' l O' EM• BOS DISTRICTLOCATION CODE <br /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR - <br /> U tavLc, U)/'Q 115�' �I(`/ S CHECK If BILLING ADDRESS <br /> BUSINESS NAME C 6 f^ i!n ft f 4/( r2;]_D/_/ I EXT. <br /> HOME Or MAILING ADIADR'EtrSl. (X ✓l. LCAP r 11— O J�(� - D(y��J! I <br /> CITY 19- STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized Ident 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 farm. <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, ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: L SCU d �O v r<r7 L.✓ DATE: Y�o <br /> PROPERTY/BUSINESS OWNERD OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IfAPPLrcANT is not the B/LLlNGPARTY 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 /> Ninformation to the SAN JOAQUIN COUNTY ENviRoNMENTAL HEALTH DEPARTMENT as soon as it is available and Yii[ne time it is <br /> provided to me or my representative. �e <br /> TYPE OF SERVICE REQUESTED: LD <br /> COMMENTS: <br /> JOiQuili <br /> 4 2 21 <br /> I^/�/� Q �01pq �� <br /> CYIW l G �W' I'1� <br /> ACCEPTED BY: EMPLOYEE#: DATE:CAM (f <br /> ' <br /> ASSIGNED TO: EMPLOYEE#: DATE: ( <br /> Date Service Completed (if already completed): SERVICE CODE:t 7� 11 <br /> E:I <br /> Fee Amount: '0 Amount Pai /�, �� Payment Date �'L ZZ <br /> Payment Type �� Invoice# Check# Ns- F— Z. Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />