Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ,6i20e 7t,3-3 <br /> OWNER/OPERATOR e <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME �'� �`F�i�,f ��KC�•G� �� <br /> SITE ADDRESS (iC_��y' � w <br /> 7 Street Number Direction ` , Street Name _ Cit ZC.i.ICso'd^e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1 C Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 25 o(I <br /> PHONE#2 EXT. BOS DISTRICT LOgCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> � CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT' <br /> v✓- <br /> HOME or MAILING ADDRESSFAX# <br /> ( �a9) a 7S 775' <br /> CITY S T ZIP (?l_/// <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 <br /> or 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 FEDERAL law <br /> APPLICANT'S SIGNATURE: 6_::_ . DATE: !S <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANA R ❑ OTHER AUTHORIZED AGENT,a„t <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 <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 S e time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: [w�- P(,� 6110� T <br /> COMMENTS: SqN15 201 <br /> JO <br /> E A Ii/ <br /> Hfq 00 AIV <br /> 'I- TY <br /> F T <br /> ACCEPTED BY: C-r( ��_� EMPLOYEE#: DATE: <br /> ASSIGNED TO: L-o 15 S-/ w, EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: OC� <br /> Fee Amount: 3 °l U `' Amount Pa 3�Q, Payment Date <br /> Payment Type Invoice# Check# Received By: _ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />