Laserfiche WebLink
SAN JOAQUI6OUNTY ENVIRONMENTAL HEALTWEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> yrs staT,o p 4"M 2� P1U 132a <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS E] <br /> i T9Tio G• <br /> FACILITY NAME <br /> SITE ADDRESS i�'tA/�Ui GNgt' STOG K.Tn 9S"2 <br /> OC�77D 6 Street Number I Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> o y 14m ST Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (ye& S93 - 3/90 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ���ttt �CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORRRu/' CHECK If BILLING ADDRESS <br /> BUSINESS NAME <br /> -/ PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 SIGNATURE: DATE: J� / <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IfAPPLICAwT is not the BILLING PART_'Proof of authorization to sign is required Tile <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. IJAY <br /> TYPE OF SERVICE REQUESTED: IVED <br /> COMMENTS: y / � i i lir] JUL 17 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEEM U 3 DATE: <br /> ASSIGNED TO: EMPLOYEE#: /5 2 DATE: <br /> Date Service Completed (If already completed): SERVING ODE: PIE:_ 1 ' <br /> Fee Amount: S Amount Paid ��'_ C� Payment Date -Z/'-7(6--7 <br /> Payment Type ✓- Invoice# Check# S ba� Received By: 2�� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />