Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Prop FACILITY ID# SERVICE REQUEST# <br /> FAc3G77 5200?735 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILrY NAME •'C1"� <br /> U-s del r <br /> SITE D sS <br /> ` � �oSt <br /> Street Number DFfrom <br /> Som Na cl ZI Code <br /> HOME Or MAILING ADDRESS (If Differeite Address) <br /> SUeet Numbar S t Nam <br /> CITY STATE Zip <br /> PHONE#1 $ � Etc APN# LAND USE APPLICATION# <br /> aR) g23 21I ��oo3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) o05 0G <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /✓ / AAA ���///n/�' <br /> `f� �✓" CHECK If BILLING ADDRE55O <br /> BUSINESS NAMEY\�v �/'! � PHONE# ExT <br /> HOME or MAILING RESSJSt_vf\ V � �C ccs/ r(�Y FAX# <br /> ( ) <br /> CIN STATE .J4 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 /> also certify that 1 have prepared this application and th.11 <br /> COUNTY Ordinance Codes, Standards, S�TEIand FE <br /> a work to be performed will be done in accordance with all SAN JonqulN <br /> R la �J <br /> X APPLICANT'S SIGNATURE: / � DATE: C( T� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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, 1, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon as It IS available and at the Same ti t I "ovidQd tome or <br /> my representative. �d ratysgs��pltS�i <br /> TYPE OF SERVICE REQUESTED: ,"tjT �H �'"�{t RECEIVED <br /> COMMENTS: <br /> to 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: I lw-f�tellA EMPLOYEE#: DATE: <br /> AsSIGNEDTO: INA ' EMPLOYEE#: DATE: —1' 2r_(7 <br /> Date Service Completed (If already completed): SERVICE CODE: OG I I PIE: ;Z3I1 <br /> Fee Amount: J1q_00 Amount Paid 1 3 • b Payment Date W • <br /> Payment Type Invoice# Check# I L9 3� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />