Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ' f, 0u1 �a CC---7C1 <br /> OWNER/OPERATOR ` / <br /> T1 to Pro"�-) I �, 1 y I /; CHECK if BILLING ADDRESS <br /> FACILITY NAMEvV 1 Y\h k`X 1 0 V/n'�,S <br /> SITE ADDRESS c%UiV�iV� <br /> f li S <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) t~�)OL J C5 —7, `) �/l�/1 t!1�(' 12CA <br /> Street Number Street Name <br /> CITY I � STATE � ZIP 0)��� <br /> PHONE#1 ` EXT. APN# LAND USE APPLICATION# <br /> C1 LA l <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR IPA C1 r C\7v pn-�1 CHECK if BILLING ADDRESS <br /> 01 <br /> BUSINESS NAME EXT <br /> X 13^n�� PHONE# + �r � I <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE CA <br /> zip 0is—z- <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 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 SIGNATUREs-4 . d��L/ lC� DATE:_ <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, 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 environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided PyII�A[ <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: ( )YY�u <br /> COMMENTS: V tV�r 1G�� P . SgN�t v 9 a 2018 <br /> EN�iAQ�"I c <br /> H�CTyo pgRT q�7y <br /> ENT <br /> ACCEPTED BY: `�� � EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1 1 1 <br /> Date Service Completed (if already completed): SERVICE CODE: (�(� I PIE: <br /> 1 GZ <br /> Fee Amount: c ,lc7Z Amount Paid Payment Date <br /> Payment Type Invoice# Check# 7 Received By: / <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />