Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />FACCO 20 <br />SERVICE REQUEST # <br />einr0 <br />OWNER! OPERATOR CHECK if BILLING ADDRESS <br />FACILITY NAME <br />,s- X. co \-0 scv \ c — -R c.,-... \ -• \,c_. <br />SITE ADDRESS <br />l:LA l,c-; Street Number <br />N ,L, <br />Direction <br />eiz,„..,..N. x_ c_5,,,Ne.— <br />Street Name <br />tS\-\-\\-c)v\ <br />City <br />c\ cl_ <br />Zip Code <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 Ex-r. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />\' 5 ,,,e,\ <br />PHONE # <br />(2R) SS-AA --?›. \-1" <br />EXT. <br />HOME or MAILING ADDRESS <br />(0 on k'. .--- Qny‘k.cktv, <br />\c,-S\i-s,„c\ <br />A <br />FAX # <br />(1)A) <br />CITY STATE <br />C 9 <br />ZIP <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 or <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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: ---11-7 DATE: \ - oc2t <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT D: v-Nr- <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br /> <br />Tile <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, geoteclmical 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 />TYPE OF SERVICE REQUESTED: POOL &PA) i-it"—et eiltsitE141- <br />COMMENTS: <br />V Wgs <br />l',; 'i <br />12641 riv i <br />M f <br />:,1 t.,1 <br />moil u <br />IREGE1\1°0 <br />/ 20 <br />Ns 1 - couNT'? <br />skt4J0R, otesi-P, N7 EtvIR0 Fp&OVE <br />k4EAL-roc' <br />ACCEPTED BY: ci-11/4 EMPLOYEE #: q3(po DATE: <br />ASSIGNED TO: <br /> *WA7-fk <br />EMPLOYEE #: b2...") <br />1 J <br />DATE: <br />PIE: .3402, Date Service Completed (if already completed): SERVICE CODE: ..9-2/2__ <br />Fee Amount: 4,2,4 , , ..-1 Amount Paid l Payment Date ,] \ 2/ 3 <br />Payment Type t_ - ---- Invoice # Check # "I `b -2_ S "Rs. Received By: (syrs— <br />END 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003