Laserfiche WebLink
0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE ,ARTMENT <br />SERVICE REQUEST <br />I <br />CONTRACTOR 1 SERVICE REQUESTOR <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 dare in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and <br />APPLICANT'S SIGNATURE: DATE: <br />�I PERAT R 1 MANAGER OTx AUTHORIZED ACEN ''p <br />PROPERTY l BUSINESS OWNER 11 Title <br />If APPLfCANT is not the BILLI G P I RTY proof of authoriladpn to sign is required <br />ator of the wner or oper <br />AUTHORIZAlocated at the <br />TION TO RELEASE INFORMATION: When applicable, , teo <br />he <br />Cal data and/or envlronmentaprope�site assessment <br />above site address, hereby authorize the release of any and all results, g <br />EAT-TH DEPARTMENT as span as it is availabPRandxhe tim <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL He it is <br />provided to me or my representative. <br />TYPE OF SERVICE Rt tlESTED: <br />COMMENTS: J <br />SAN JflAflDIN � O ALS <br />ENVIRflNM <br />HEALTH DEPARTMENT <br />EMPLOYEE #: <br />APPROVED BY: (Z�- I <br />h r ,` EMPLOYEE #: y ',� <br />ASSIGNED TO: '1 1, I,IL ' <br />SERVICE CODE: 0 <br />Date Service Completed {if already completed}: <br />Amount Paid 7 � D payment Date <br />Fee Amount: 1$;0 1 <br />Payment Type Invoice # ICheck # -�' 11) <br />EHD 48-01-025 <br />REVISED 6-5-02 <br />DATE: <br />DATE: <br />PIE. <br />I'p � <br />Received By: <br />SERVICE REQUEST FORM <br />