Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> TypE of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ggCa q�L P� Fid aC) 5tW371 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> I -) <br /> - <br /> FACILITY NAME �q O <br /> � rtL .4 t" P^1 l I l <br /> SITE ADDRES <br /> Street Number I Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Sheet Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( I <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR O/� CHECK if BILLING ADDRESS v- <br /> Ati �ui� ti <br /> BUSINESS NAME PHONE# ExT' t I it <br /> 1 �� ,l�fL U;_o : (� ✓ l aloo.� 2tj ?8 <br /> HOME or MAILING ADDRESS FAX# <br /> PAv Ro �` rbc (Z/J 1381_15/7 <br /> CITYSTATE C� ZIP <br /> CJ ` is ,`a �t +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 <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 ER /laws. <br /> APPLICANT'S SIGNATURE: Com/ DATE: 6S <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT R fl l Fo 2 C <br /> If APPLICANT is not the BILLING 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: LIS j F lry <br /> 1 REVF`v p <br /> COMMENTS: C V .^�• l A C Z C�ti a P+ tn f�Y ( �p04 <br /> (S E S P, ons 3(��sSAN JOAOUIN ENT NN <br /> H��Fi DEPAI�T�ENT <br /> APPROVED BY: ��C ICI I p_,t EMPLOYEE#: 'S Z/ DATE: <br /> ASSIGNED TO: S���sc,J EMPLOYEE#: 3-7 DATE: S 2 -7 to <br /> � <br /> Date Service Completed (if already completed): SERVICE CODE:, P I E: 3. Q <br /> Fee Amount: R 2--7 5 C,J Amount Paid a-7T -71D Payment Date /-"'-7(c)cf <br /> Payment Type L/ Invoice# Check# 33 Received By: / <br /> EFID 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />