Laserfiche WebLink
SAN JOAQU._ COUNTY ENVIRONMENTAL HEALTI ALPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />R6\-6 61 0015 7_, <br />SERVICE REQUEST # <br />45e.00 7,&,5- <br />OWNER! OPERATOR 11 Z:9(4' <br />CHECK if BILLING ADDRESS <br />FACILITY NAME , rx---- <br />SITE ADDJNSS <br /> j Street Number b-ife:tion -.711LP4e71024--2 __re_t Name <br />* <br />144 itv Mee 67 <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS& <br />BUSINESS NAME / 4r4 ,W) 0 ' 0/Z <br />PHONE # <br />(9"47 ) <br />FAX # <br />( 1 ) <br />Exy. <br />3-3 ‘(-.3 ro? <br />HOME or Ravi) G ADD SS <br />re /1, ' 2/) <br />Cire /1,76,0. 0 ,A, STATEL: -7/ ZIP 95))9 <br />BILLING ACKNOWLE GEMENT: 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 s. the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST TE-all'FED L I wS. <br />-/YAPPLICANT'S SIGNAT DATE: <br />PROPERTY / BUSINESS OWN• OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <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 />rovided to me or my representative _ <br />J ) J <br />TYPE OF SERVICE REQUESTED: -C, Pe OP-AAA) <br />COMMENTS: PAYMENT <br />RECEIVED <br />APR 1 9 2013 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />ACCEPTED BY: nac EMPLOYEE #: ( Al etTp3 <br />ASSIGNED TO: <br />1476gC <br />EMPLOYEE #: # 1 DATE:1 /i 03 <br />Date Service Completed (if already completed): SERVICE CODE: rd_ p____ PIE: <br />Fee Amount: a SY) °U <br />Amount Paid 6;25E5 Payment Date A 0 q i 1 3 <br />Payment Type / q Invoice # Check # ?e,(54„ Received By:i _et <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003