Laserfiche WebLink
SAN JOAQUIP )LINTY ENVIRONMENTAL HEALTH PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />PHONE# ExT. <br />SERVICE REQUEST # <br />ciAs s ,A t ( 0/,1 <br />CITY STATE ZIP <br />ACCEPTED BY: <br />EMPLOYEE #: <br />OWNER / OPERATOR <br />❑ <br />!t f/AM <br />A 6� <br />CHECK If BILLING ADDRESS <br />� / <br />FACILITY NAME q L L� y SEAM CE 577-o47 ( ON <br />SITE ADDRESS <br />AST-�ARQb I#V(7 WA� <br />Fee Amount: <br />S o c i<c O N <br /><15520 � <br />GStreet Number <br />Direction <br />Street Name <br />Invoice # <br />Cit <br />Zi, Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE#1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />(20)4 6 6 - T516 <br />PHONE#2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# ExT. <br />HOME Or MAILING ADDRESS <br />FAX# <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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATU�R7rE: 4 Ar ZDATE: 4Z2 7 <br />PROPERTY / BUSINESS OWNER OPERATOR/ MAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 <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: J t <br />S <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: 14 <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />