Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> T-e 5R008580 (D <br /> IOWNER I OPERATOR <br /> f-- <br /> — d CHECK If BILLING ADDRESS <br /> FADILITY NAM '7— l <br /> ^'� C //�� le- <br /> cr t� <br /> SITE ADDRESS /3r / tTi � "4igt,4-Qe I1 31.b <br /> Street Number Direction Street Name / CI ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#t Ex . APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 Enr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR '/ <br /> E �� //Q CHECK If BILLING ADDRESS <br /> BUSINESSNAME {{{"'___��` TTT777 PHONE# E <br /> l RN <br /> HOME or MAILING ADDRES FAX# <br /> CITY ` STATE ZIP <br /> BRIANG 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATUF DA16�: 01 q/2d/2 7 <br /> PROPERTY/BUSINESS OWN OPERATOR/MANAGER LJ OTHER AUTHORIZED AGENT❑� <br /> If 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: h ' t R F <br /> COMMENTS: F <br /> SfP 20 2to <br /> 0 <br /> /�S 1NJOAQUtN ?2 <br /> "IC�RO4L"F Caudill7)- <br /> ACCEPTED <br /> JYACCEPTED BY: EMPLOYEE#: / 2,L 3 DATE: e7�ry 2� <br /> ASSIGNED TO: EMPLOYEE#: 1 4' Z—DATE: L� /' ?,7— <br /> Date <br /> Z <br /> Date Service Co feted (if already completed): SERVICE CODE: I HE 0 Z <br /> ZPaymFee Amount: 1 Amount Paid / Payment Date 12-2— <br /> Payment <br /> ent Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 Vol l�11 V <br />