Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />I--) Oti f4tv‘ 641.4- t cs?-h. to le 4 <br />1 FACILITY ID # <br />1 FA Ob0 ) aoeo, <br />SERVICE REQUEST # <br />5C_60 ---) ) ---) <br />OWNER / OPERATOR <br />CHECK if f- BiLLING ADDRESS <br />FACILITY NAME De14-a_ C__—,g1 rd P,14 ai4 .-c-S <br />SITE ADDRESS <br />11 03 Street Number Direction <br /> LU 444#1 're( ., <br />Street Name <br />T <br />AinCV,i/cD.Y‘ <br />I _Silt , _ Zip Code <br />HOME or MAII NI., ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( 04) I-/7. <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATIC1N CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ,--, <br />3 ear F I* 14-C, CHECK if BILLING ADDRESS 0 <br />BUSINESS NAME cm...,otv, pools 2 fc, ,c, <br />(O') <br />PHONE # <br />s 37- lo --oc) <br />En'. <br />HOME or MAILING ADDRESS <br />,SCCO rig-4v 14chne- r k <br />/ FAX # <br />(ol ) S37- bssq <br />CITYC. <br />._ etre< STATE ZIP co- <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 Of <br />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, STAT d FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: (7. ."'" (4 9 / <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT Er S )05 <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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided tAme or <br />/1.3 -Fb Iti TYPE OF SERVICE REQUESTED: -po-u-L., R_Q ;(1, to ct I \cAp 1 c (/ Li c <br />COMMENTS: Ju/v , o r. e _ p 1 "I.:46c <br /> La 41°41Q11 44, _ilti,,,,,,,Itt c <br />"If ikillk4f t( 41041 <br />ACCEPTED BY: C.-52(...\ EMPLOYEE #: DATE: (I, . c9._ () . ) cc) <br />ASSIGNED TO: pec\ (.-7-cc q EMPLOYEE #: DATE: 6., _ v-i_ I Le, <br />Date Service Completed (if already completed): SERVICE CODE: ‘- P/E: . <br />3 <br />.,0a <br />Fee Amount: c.....) Amount Pair( ,(e 0 0 0 Payment Date <br />Payment Type Invoice # ChteIC # 4,e2,2_?-1-117 Recei ed By: <br />my representative. <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)