Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# �IC�REQ�� <br /> OWNER) PERATOR <br /> CHECK If BILLING ADDRESS <br /> FAciu7v NAME , <br /> S �U(I'` yrs{(1( VA y j / i <br /> SITE ADDRESS 5 Jl�� ) ILLI-(� �� �. ,� JA V l� 1, / 5 Z� <br /> Street Number Direction Street Name Ci Zip Code <br /> HOE or MAILING ADDRESS (If Different from Site Address) 2r7 / � <br /> �C;(O� Z Street Number P v1��'Zf el Name <br /> CITYL A k��n $TAjE ZIP L332 <br /> o #1 r/ EXT. APN# LAND AND USE APPLICATION# / <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME `\s '�� \ I # � I �,LI y {-�Exi. <br /> HOME or MAILING AD gRE S- � _ 1 FAX# <br /> (� e 12►2 V'V Y1 ( ) <br /> CITY i4 r) STATE/' 1!' Zip C --2 <br /> BILLING ACKNOWL�JDGEMENT: I, the undersigned property or business owner,l/operator or authorized agent of same, <br /> acknowledge that all site and/or project specific F-NVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project Or <br /> activity will be billed to me or my business Id igd on this form. <br /> I also certify that I have prepared t . is on Ind that / orm will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standa s,.ST a F ERAL I �j <br /> APPLICANT'S SIGNATURE: DATE: (/ / / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ NAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING P TY,proof of authorization to sign is required 7'lrle <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 provld�C�� Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: , <br /> 1 <br /> HRON/N c <br /> ACCEPTED BY: �j EMPLOYEE#: (�]' DATE: I �� <br /> ASSIGNED TO: v� /� EMPLOYEE#: 35` ( r DATE: I <br /> Date Service Completed (if already Completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid �CJ Payment Date r j <br /> Payment Type ;5 . Invoice# Ch ck#6 7L 4fl�,3 F Rece' ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />