Laserfiche WebLink
n _. <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />PH E ExT• <br />SERVICE REQUEST # <br />(JCS ld► 1 <br />CITY i5- /y y j. n STATE M_ZIP <br />OWNER/ OPERATOR <br />__ AC11) Dc) <br />CHECK if BILLING ADDRESS El <br />' <br />FACILITY NAME PIAQ �� T 1 LICIL <br />SITEADDRESS QM <br />C",��M1 <br />l a t ��_( J <br />` <br />1 1 {� <br />DATE: <br />Street Number <br />Direction <br />Street Name <br />Cit <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />W37S p <br />Paymen Date <br />Payment Type <br />Invoice # <br />Street Number <br />Check # S(� �� <br />Street Name <br />CITY v�t1'U1 c , <br />Mkf <br />STATE Opt zip <br />J� <br />PHONE #1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REOUESTOR <br />REQUESTOR <br />�� / r \�\ CHECK If BILLING ADDRESS <br />�)�j <br />BUSINESS NAME FF n /!' �, \ ( <br />Lk 4 _ Wt al�lV 1 <br />PH E ExT• <br />HOME or MAILING ADDRESS <br />2536 wl bwflim <br />FAX <br />( <br />CITY i5- /y y j. n STATE M_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: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BiLLINGPAR TY, 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 <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 />At A.VO4T <br />TYPE OF SERVICE REQUESTED: S12 <br />- <br />j:J-JECEIVE� <br />' - - <br />COMMENTS— ---- _ -. <br />17 <br />Q��N COUNTY <br />SANENVIRONMET'"LNT <br />HEp,L.T1-1 DEPAR <br />ACCEPTED BY: .� <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: �� <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: C <br />P / E: <br />Fee Amount: S <br />Amount Paid <br />W37S p <br />Paymen Date <br />Payment Type <br />Invoice # <br />Check # S(� �� <br />Received By: <br />EHD 4.8-02-025ffi��, <br />. <br />�L <br />