Laserfiche WebLink
SAN jOAQUIN COUNTY ENVIRONMENTAL HEALTH iJEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> �. c r� CHECK if BILLING ADDRESS <br /> FACILITY NAME ( <br /> jA L: L2 I <br /> /die& & A <br /> SITE ADDRESS �` y <br /> I A <br /> Street , Cumber Direction SQet N me �-� I�Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 `/,��1/ E.T. APN# LAND USE APPLICATION# <br /> (96q _7, `VV l v <br /> PHONE#2 EXT. BOS DISTRICT -7� LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> (! 1 <br /> BUSINESS NAMErJV" 1 <br /> PHOE ExT. <br /> c u JC <br /> vT� <br /> HOME or MAILING ADDRESS FAX# <br /> Ilk DIP— <br /> CITY STATE 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 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,$TATE and FEDERAL laws. (l <br /> APPLICANTGNATU�RlE: I ^ A DATE: S <br /> PROPERT BBUSINE315NM IQAI-, OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT ❑ ULt J -(2-- <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS pryVided to me or <br /> my representative. I 'l /A <br /> TYPE OF SERVICE REQUESTED: V d SU 1�� v r) (� <br /> COMMENTS: Ut 1 0 C2016 <br /> t/ <br /> H�CIVV/q pMN COIN <br /> rr <br /> LTH OEpq TMF� <br /> ACCEPTED BY: RLOA6OI 1 Q O EMPLOYEE#: DATE: <br /> ASSIGNED TO: VAA c, EMPLOYEE#: DATE: <br /> G IZ �� <br /> Date Service Completed (if already completed): SERVICE CODE: S C (� PIE: <br /> Fee Amount: I cl I <br /> Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />