Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busi sus o�jProperty //�� FACILITY IIDD# SERVICE REQUEST# <br /> 6a� �}� ko-tl C�nv}et,e� <br /> OWNER/ OPERATOR N <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME C � <br /> SITE ADDRESSY64?:- <br /> HOME <br /> ode <br /> y <br /> Street umber It D�ire_ction \ StreeTtlN me Ci l.� 1 Zi ode <br /> HOME Or MAILING ADD ESS (I I rent from Site Address) <br /> Q Street Number Street Name <br /> CITY STATE ZIP <br /> -PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ice) 2z�, A <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> ( <br /> HOME or MAILING ADDRESS 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 bus' ss a tified on this form. <br /> I also certify that I have prepared is appl' ark that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand rds' d RLDERAL laws. t� <br /> APPLICANT'S SIGNATURE: DATE: t {L v <br /> PROPERTY/BUSINESS OWNER❑ E TOA I NIANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILI NC PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE Ip FORMATION: 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: ca --� N <br /> COMMENTS: <br /> JUN 12 2006 <br /> SAN JOAQUINI COUf1Ty <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: b P I E: 3� <br /> Fee Amount: "' Amount Paid Payment Date <br /> I <br /> Payment Type Invoice# Check# _ Rekeive By: 'i <br /> EHD 48-02-025 ,SR FORM:(Goldeo Rod) <br /> REVISED 11/17/2003 <br />