Laserfiche WebLink
SAN JOAQUkiN COUNTY ENVIRONMENTAL HEALTH jJEPARTMENT <br />SERVICE REQUEST <br />F --- <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST# <br />OWNER / OPERATOR <br />Pq & <br />CHECK if 0 <br />kdls� <br />lk& cy'A <br />§1WjaAEgLRM <br />m <br />FACILITY NAME 1/ 1) <br />V16, 11'e, Ila C' <br />'�n o <br />SITE ADDRESS <br />, - 7 <br />4- � <br />I <br />jl� <br />5k? C) /t <br />, <br />I qs-a-� <br />— Street Numb* r <br />Dir ion <br />Fee Amount: <br />Stree <br />city <br />Payment Type Invoice # <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Received By: <br />-t--- (-"/ <br />I <br />( �� <br />Street Number <br />et Nanw <br />CITY <br />STATE r zip <br />q5-�6 <br />PHONE #1 EXT. <br />APN # <br />LAND UsE APPLICATION # <br />PHONE #2 Exr, <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS 0 <br />BUSINESS NAME <br />PHONE # EXT. <br />HOME or MAULING ADDRESS <br />FAx # <br />CITY STATE zip <br />BILLINE. ACKNOWLEDGEMENT: 1, the undersigned prop" 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 <br />or 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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY/ ftswms OWNERE3 OPERATOR/ MANAGER CI OTHER AUTHORIZED AGEINTO <br />1fAPP,r.tc,4NT is not the Bum PARTY. proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical 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: <br />COMMENTS: C- kc'"—Ou <br />r <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P / E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type Invoice # <br />Check # <br />Received By: <br />EHO 48-02-025 SIR FORM (Golden Rod) <br />REVISED 11/17.;2003 <br />