Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHDEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property (FACILITY ID# SERVICE REQUEST# <br /> S <br /> OWNER 1 OPERATOR <br /> d VY t�`V I CHECK If BILLING ADDRESS CI <br /> FACiLI NAME 5 <br /> 4V V <br /> I <br /> SITE ADDRESS �iZYCf� lt� /6 <br /> Street Number' Direction city �Z Code <br /> HOME or AVAILING S 7 i'Z ADDRESS (if Different from Site Address) f/ A{ <br /> ;l �1 J o� Street Number `—" Street Name <br /> CITY 6 STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (q69 (o a,—L-4S'I D.- <br /> PHONE 42 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �� CHECK if BILLING ADDRESS <br /> ch- <br /> BUSINESS NAME PHONE# ExT• <br /> W r1.1 s o--Z <br /> HOME or MAILING ADDRESS FAX# <br /> �3 <br /> CITY t t STATE I 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 d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and „EDERAL laws. <br /> APPLICANT'S SIGNA DATE: 5-1f <br /> PROPERTY/BUSINESS OWNER OP RATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ �1�S I �'� <br /> IfAPPLIGANr'0'isnot'ikeB LING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 environmentallsite assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time It is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: .� <br /> COMMENTS: <br /> iv n <br /> 1 V <br /> 14 <br /> ACCEPTED By EMPLOYEE#: DATE: / <br /> ASSIGNED TO: EMPLOYEE#: DATE:�j��'� <br /> Date Service Camp[eted (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 3/ O, 00 Amount Paid ,Z�j Payment Date <br /> Payment Type >�� Invoice# Check-# * d tf� Received By: <br /> RPA <br /> EHD 48-02-025 • ECEI V,f <br /> ED��R FORM(Golden Rod) <br /> 07/97/08 MAY 15 Z <br /> SAN JOAaU4H COUffff <br /> ENVIROMEWTAL <br /> �- -- _ HEALTH Di:1 ARTME ff - - - — <br />