Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type Bu iness or Pr erty FACILITY ID# SERVICE REQUEST# <br /> ,rt i�vo151 c�� S <br /> OWNER/OPERATORc <br /> L ^ Dou(�- <br /> 'Uer00 `�y�l�( nn �nCHECK if BILLING ADDRESS <br /> FACILITY NAME (�, 1 <br /> SITE ADDRESS <br /> y <br /> t J Street Number Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PH NE#1 EXT. APN# LAND USE APPLICATION# <br /> ( r-�b q900 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME f 1 (f(�A EXT. <br /> ffld��a- v ��L P N lW <br /> HOME or MAILING ADDRESS l! FAX# <br /> KW ( ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLE GEMENT: 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,&PTORIMANAGER <br /> d FEDERAL laws C� <br /> APPLICANT'S SIGNATURE: ./-/� DATE: q_�l C,J <br /> PROPERTY/BUSINESS OWNER❑ 2 OTHER AUTHORIZED AGENT ❑ <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: PAYMENT <br /> COMMENTS: RECEIVIMU <br /> 4 2018 <br /> 1 U 'C6 4 2)v -3r SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL jIgALIH ARTMENT <br /> ACCEPTED BY: n EMPLOYEE#: DATE: 2_/ A-11 CC <br /> ASSIGNED TO: ' EMPLOYEE#: DATE: \L/`/ <br /> Date Service Completed (if already completed): SERVICE CODE: l P/E: llvl U 2 <br /> Fee Amount: Amount Paid G r Payment Date 1 L <br /> Payment Type S Invoice# C:htrk# Received By: Rr <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />