Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />ilici (24 0(6- (r74e ft----e_ <br />FACILITY <br />ou 0 'ILI <br />ID # <br />6 <br />SERVICE REQUEST <br />1Q- (AY-hi <br /># <br />lq <br />OWNER! OPERATOF2 j R <br />ott+ g___ <br />CHECK if BILLING ADDRESS <br />FACILITY NAME0 I A, <br />C.C, (ON b R-WDOO 5- <br />SITE ADDRESS, <br />00 <br />Street Number Direction <br />ii0109-(5-1--it Pt:76-er-TS <br />Street Name <br />57 -C-r--61D <br />itv <br />24) 7 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Cirr STATE ZIP <br />P NE #1 <br />107) q et Z 7 75- Ext' <br />APN# LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTORm <br />AOLU C 05-1 DAex Poo l c CHECK if BILLING ADDRESS LJ <br />BUSINESS NAMER . , , <br /> <br />CAP _()‘")-t-Do,- 1) 00 1 5 EXT. i 1 s3 7 - b cc) 0 <br />Hor9L e)( <br />MAILiNG ADDRESS <br />) (";--2- (2(8 5-32 —W i7 <br />CiTy 0 Lo tit _te ( STATE ZIP 1 f-) 0 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 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, STATE DERAL laws. <br />APPLICANT'S SIGNATURE: DATE: /7--- (e) <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 127 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 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 to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: IR j24a:A1112071,0666/ POP alleC <br />a, .:Ezi), <br />COMMENTS: /1-e, 7- t-it_ t2c..,0 L_ <br />3---e4 (0`N-e---e C (A tia-i) N.) -e_l -D (1._ f_t f rO C <br /> <br />,r01, . irt• . <br /> <br />14,Jo " 0 .9 <br /> <br />avi4,114001 c0/6 <br />a 11,ftaionqr-rorrh ACCEPTED BY: <br /> <br />EMPLOYEE #: DATE: tqf 14 li <br />ASSIGNED TO: <br />, ,f1, In 1 e r,1 0. rYi f re z EMPLOYEE #: DATE: t trill (' <br />P/E:---, 0 62, Date Service Completed (if already completed): SERVICE CODE: cc ,) 3 <br />Fee Amount: V „21 45 Amount Pai47S. do Payment Date II <br />/ <br />Payment Type /-6 (/A___ Invoice # Check # (/ 2S-5- 4.2 <br />i <br />Recei ed By: ar <br />co4k_ 12. b <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />07/17/08