Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH OEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />1)k-is6 C t <br />FACILITY ID # <br />c- 6 ( <br />SERVICE REQUEST # <br />:.2-00 &2.—T // <br />OWNER / OPERATOR <br />CHECK if <br />I <br />BILLING ADDRESS <br />FACILITY NAME 1CI a jj <br />l.i ( Ki 0 <br />SITE ADDRESS 3 ci( <br />Street Number <br />0 <br />Direction I in S eet Na 1 et <br />V S37fc <br />Zip Code Tr Cit <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CI TY STATE ZIP <br />PHONE #1 Ext. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR <br />— <br />CHECK if BILLING ADDRESS <br />I4 <br />BUSINESS NAM -7 k_c, C2- PHoliA EXT <br />— <br />HOME or MAILING ADDRESS <br />'9* 0 <br />FAx# <br />Cm( STATE(79 ZIP ...4..s--9- 7- <br />BILLING 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 a nd t <br />COUNTY Ordinance Codes, Standar <br />e work <br />L laws. <br />.. be perfor.• A' will be done in accordance with all SAN JOAQUIN <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER 0 W PERATOR / MANAGER 0 ( 0 ER AUTHORIZED AGENT 0 <br />C.)C91-3k2-'- If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Titl: <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 />PAYMENT TYPE OF SERVICE REQUESTED: b 12936u-J\ RECEIVED <br /> V & <br />COMMENTS: <br />JUL 1 4 2011 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: EMPLOYEE #: ,91 iiy DATE: <br />ASSIGNED TO: i_ rtior.„( e A 21, EMPLOYEE #: q --z, (3 DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 2 <br />0) .--- 2 Z . P i E: 13602_, <br />Fee Amount: t/1 4 Amount Paid 0? X7 , -- Payment Date 7/( Ltd( /( <br />Payment Type Invoice # Check # otVc6 ) R4ceive By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 R A <br />. <br /> 1. <br />kte <br />SR FORM (Golden Rod) <br />