Laserfiche WebLink
of Business or <br />OWNER / <br />--c---• 11A1 ,v11 t'""I I t riL• 1" 1 HL X11-1), 111 U.EYANI INIE'NT <br />SERVICE REQUEST <br />FACILITY !D # SERVICE REQUEST # <br />COO 7][,5A(o <br />S �� <br />FACIL7 NAME <br />SITE ADDRESS S`vr-� <br />Stleag e� Direction <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />CITY <br />PHONE #1 <br />( <br />PNONE #2 <br />EXT. <br />ExT. <br />APN # <br />CHECK if BILLING ADDRESS D <br />STATE ZIP <br />LAND USE APPLICATION # <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUEST <br />0 CHECK if BILLING ADDRESS CI <br />BUSINESS NAME ; r <br />P ) � <br />HOME or MAILING ADDRESS F <br />CITY AZ I STATE ZIP C% <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 FEDERAL la s. <br />.APPLICANT'S SIGNATURE; DATE: <br />�J <br />PROPERTY /BUSINESS OWNER ❑ OPERATOR /MANAGER ❑. HER AUTHORIZED AGENT <br />-- If APPLICANT isnot the BILLINGPARTY proof of authorization to sign is require 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, 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: PAYMENT <br />RECEIVE. <br />-- - -- - OCT 0 8 2009 <br />SAN JOAQUIN COUNT( <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED B <br />—EMPLOYEE #: DATE: <br />ASSIGNED TO: (� / <br />Date Service Com <br />EFeent Type <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />0 EMPLOYEE M"Payment <br />(if already completed): SERVICAmount Paid S ate <br />IInvoice # <br />Check # 1 It S <br />DATE: <br />PIE: <br />0 <br />Received By. N%T <br />'�YSI��QRC'1�i(�ord�[►�Rod); 'r <br />