Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />Cilfek-- <br />SERVICE REQUEST # <br />Cr7-4-77 .--OZD <br />OWNER i OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NA ,,E., <br />e--..-- vir.)-ed <br />SITE AD ESS , 3LICO <br />Street Number Direction <br />\AAA&I fl 0\z_ 1-trr-,1-7/i75 <br />Street Name <br />fer-604,-TA., <br />City g_5--,Qe,c/ Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Crry STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR . <br />CHECK if BILLING ADDRESO <br />BUSINESS NAME <br />Of' OP At9/5' <br />PHONE # <br />lt) 7 - <br />EXT. <br />HOME or MAILING ADDRsLY <br />P:r7D Molq it, (),4 <br />FAX # <br />00q) 37v - 6 -?'2 7 <br />CITY Z....,00/ k/k../ STATK, 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 FED v L laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR/MANAGER 0 <br />DATE: <br />OTHER AUTHORIZED AGENT Dr <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 <br />above site address, hereby authorize the release of any and all results, geotecbnical 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 />TYPE OF SERVICE REQUESTED: 1/6.--7/3 Rie)(, r(dd91/ 1-pc—cf. PAYA,4p. REce NT <br />COMMENTS: /VED <br />FEB 23 2009 <br />SAN JOAQU . 1- H ENVIRONV6,9UNTy <br />11 "PARIVNT <br />ACCEPTED BY: <br />'414- <br />EMPLOYEE #: 0-...3,1: DATE: <br />ASSIGNED TO: WI? W.—CD <br />EMPLOYEE #: otbfil DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 5-- 2, 2,,- PIE: a <br />Fee Amount: 7 1 <br />,.... <br />° , Amount Paid 0?//30 `------- Payment Date 1/07 3 z2 e:?, <br />Payment Type , Invoice # Check #(...; ( eceived <br />SR FORM Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003