Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />5ROD S -7 4o og <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS <br />Street Number Number Direction Street Name City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Crri, STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # <br />/ / CO .— /-5—'0 — 0---C7 <br />LAND USE APPLICATION # <br />PHONE #2 ExY. <br />( ) <br />BOS DISTRICT ...2.._ LOCATION CODE <br />I <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS 151 <br />BUSINESS NAME c.N <br />\j •L'J'Ake-'0'5 <br />—3 <br />CC_\ W.I.Ne..0 \V', -IN \ ( <br />PHONE # <br />( 2-°Ct ) c 4 9. <br />EXT. <br />HOME or or MAILING ADDRESS <br />\4Yt- <br />\ <br />*6- <br />FAX # <br />( 2.c›C ) 3 45 . 31stib <br />CITY <br />.•'\ .--)r..,C\ <br />STATE „ <br />(--, rr <br /> ZIP n <br />IS <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 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 SIGNATURE: <br />DATE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER <br />OTHER AUTHORIZED AGENT a <br />nw\ kqt)e..i <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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 ENVIRONMEN FAL 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: R c f-.../ 6_4_ c."7-7_, 4.6•,,,..e (.4.0 .•- (-____ 76) (._ ,4_,4d C /,-- l E C Cem M ENT <br />COMMENTS: RECEN -1-) <br />JIM 1 9 2009 <br />INIC°UN-ri SAN 3C4V)V,IIMEN-ii5,1- . <br />ENVIB°' ARTMEN <br />HE-ALM DEP <br />ACCEPTED BY: 0 c I_ t j el g.A. EMPLOYEE #: <br />0 Q> 2 I <br />DATE: 6, <br />ASSIGNED TO: ,. <br />EMPLOYEE #: (0 • ? 1,-...3 DATE: „ iterq/oci , - <br />Date Service Completed (if already completed): SERVICE CODE: 5.--7 2 PIE: <br />Fee Amount: Liz) 7 Amount Paid --c g_ D . 0 Payment Date <br />Payment Type Invoice # Check # 3 i -)._ -2_?- Received By: <br />- is-aq <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod)