Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SUVICE R� T# <br /> OWNER/OPERATOR <br /> /� CHECK If BILLING ADDRESS <br /> SA� <br /> FACILITY NAME [ ` (((•••ttt///lll(((/// <br /> N pal DL u �C, <br /> SITE ADDRESS {��rpp•.D� c L �nq DO S-T S��G/�T�A) gSe�47i <br /> Qv t L�r t eet Number Direction t� f"I Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. qpN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOss,fiV 151pfal• <br /> CHECK If BILLING ADDRESS <br /> EE <br /> BUSINESS NAME PHONE# EXT. <br /> N N P��olct,�n�t �N , Y• ���-s�r3 <br /> HOME or MAILING ADDRESS FAX# <br /> 713 A/, 9 L 015,e4D 0 ST- <br /> CITY <br /> CITY 57-6) <br /> 3/-J STATE ZIP CfS�OZ <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 SIGNATURE: _ DATE: 7,9-100 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> I(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 /> 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 /> NOV <br /> SAN✓O <br /> ENV gQUIPI <br /> y�LTHON O ry <br /> ACCEPTED BY: ��1LArv1 9a <br /> v'(a EMPLOYEE#: n �/] DAT[: I I /�� r <br /> ASSIGNED TO: GL 11m EMPLOYEE#: (/J DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: ( WAmount Pai /sa vQ Payment Date f 1 <br /> Payment Type G� Invoice# Check# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />