Laserfiche WebLink
SAN JOAQUTN Ct TY ENV.y-Or+".'.ENTAL HEALTH DEP 'MENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C-1 p-s r�o�l � cin � � q -P-c) L -7 3 k3' <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME V <br /> SITE ADDRESS <br /> Street Number Direction Street Name cityZi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> �- SO &u V {, <br /> Street Number Street Name <br /> CITY Scat � o s� <br /> STATE zip n�/ <br /> PHONE#1 EXT APN# LAND USE APPLICATION# `7 l <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR M 4F,r t TO HA <br /> , ) CHECK if BILLING ADDRESS <br /> BUSINESS NAME I PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY C a-L1 i c STATE 0—k ZIP qT1 <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 <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: "^Y l._i e i�.i ., { �.6 L.: DAVE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLTNG 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite 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: U 5, PAYM <br /> COMMENTS: ItiS 'C r 0�/ �# t Y <br /> Co��J JUL 12 zac), <br /> s <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> In I HEALTH DEP <br /> ACCEPTED BY: EMPLOYEE#: l DATE: J Z O <br /> ASSIGNED T0: EMPLOYEE <br /> DATE: <br /> aGlc <br /> Date Service Completed (if already G <br /> completed): SERVICE CODE: 1 C.' P/E ?,G <br /> Fee Amount: C Amount Paid Payment Date " ( � <br /> Payment Type ✓/ Invoice# Check# �` Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />