Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERAT <br /> eCHECK if BILLING ADDRESS <br /> FACILITY NAME /� _ I <br /> SITE ADDRESS I l—[.L1 ' ,^/� <br /> Street Number Drection 'r5treetN�e 'C ` C� <br /> It, � Zi Gotle <br /> HOME Or MAILING ADDRESS (If Different frnm situ Addre«I P <br /> Street Number r� ` �tr et Name <br /> CITY �n STATE ZIP ^ I <br /> PHONE#1 ExT 1 , ` APN# LAND USE APPLICATION# `�` <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> I ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME - PHONE# EZT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE 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,STAT nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: ! <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I MANAGER OTHER AUTHORIZED AGENT-B <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 a above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the Same time if Is provided l0 me Or <br /> my representative. JOA. <br /> c <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: vej <br /> Cer^s , <br /> SEp? 1 <br /> say,oq ?018 <br /> H fM/RpOINC <br /> GJ 10 �5 TND p�N Nry <br /> ACCEPTED BY: EMPLOYEE#: DATE' <br /> ASSIGNED TO: I n G EMPLOYEE M DATE <br /> Date Service Completed (if already completed): SERVICE CODE: b PIE: -I ©� <br /> Fee Amount: 1 --5 Z' Amount Paid ,Ov Payment Date L21 [ <br /> Payment Type Gl L , Invoice# Check# 3Rece ved By: <br /> EHD 48-02-025 t� SR FORM(Golden Rod) <br /> 07/17/08 <br />