Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK If BILLING ADDRES <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />HOME or MAILING ADDIRss <br />SITE ADDRESS <br />ZS Street Number <br />Direction <br />/ <br />KC%�nP7,C/1 <br />Street Name <br />CITY Lodi* <br />Cit <br />Zip Code <br />HOME Or MAILING A DRESS (If Different from Site Address) <br />2 Street Number <br />DATE: <br />(S eet Name <br />CITY <br />STATE <br />_I <br />/f ZIP <br />PHONE #1 C /7 I /1 EXT. <br />l { 2�- r <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />(/I v ` <br />CHECK If BILLING ADDRES <br />BUSINESS NAME <br />COMMENTS: 201 <br />0 ti/r ► 9ffV VCOONNEgH D IENVR" <br />/'C> RAR'rmEND 4,-r q' 'l/ `��S(� <br />�WeT We`er f'v' b �c� <br />PHONE# <br />EXT. <br />HOME or MAILING ADDIRss <br />EMPLOYEE #: fl <br />FAX # <br />! <br />CITY Lodi* <br />STATE CA <br />ZIP I �j,5� <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 />1 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: `��' DATE: l <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 10 <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 />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It Is prct,"4"0 tq.Ll"lP,Or <br />my representative. _'s <br />TYPE OF SERVICE REQUESTED: <br />LI <br />COMMENTS: 201 <br />0 ti/r ► 9ffV VCOONNEgH D IENVR" <br />/'C> RAR'rmEND 4,-r q' 'l/ `��S(� <br />�WeT We`er f'v' b �c� <br />ACCEPTED BY: <br />EMPLOYEE #: fl <br />DATE: <br />! <br />ASSIGNED TO: <br />EMPLOYEE #: ( 1 p- <br />0 <br />DATE: <br />Date Service Comp* if already complet d ' <br />SERVICE CODE: <br />® <br />PIE: Y15 OA <br />Fee Amount: 5 o <br />Amount Paid <br />JC 2 <br />Payment Date / 1 <br />�-7 I <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod) <br />1 <br />7 <br />�A'r <br />