Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busin ss or Property FACILITY ID# SERVICE REQUEST# <br /> u <br /> OWNER/OPERATOR { <br /> CHECK if BILLING ADDRESS O , <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 6 I d <br /> Strlee9,-de�' Fa".tFon Street Name CI ZI Code <br /> HOME Or MAILING A RESS (If Different from Site Address) <br /> t Street Number Street Name <br /> 0TY STAT ZIP <br /> I <br /> PHONE#1 / Exr. APN# LAND USE APPLICATION# <br /> �-"7 -4�b <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR IteCHECK if BILLING ADDRESS 0 <br /> BUSINESS NAME �„n PH NE# Exr. <br /> MOL Co 0 <br /> HOME or MAILING ADDRESS FEU(# <br /> CITY 2a MA, �� STATE Zip <br /> 23 <br /> BILLI G ACKN LEDG MENT: I, the undersigneda-property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges 2SSOCi2ted 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: / D -- ?:: f <br /> i <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I MANAGER ❑ HER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARrr,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 environmentallsite assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided femme or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: S M-1 r 4 <br /> COMMENTS: [ 28 ? 6 i <br /> S4Af 01r� <br /> 11E-ACTOR MN► !! <br /> k o BAR A(Nry <br /> FNr <br /> ACCEPTED BY: /' A/Lw <br /> /r )ei O EMPLOYEE#: DATE: I(� �b �/�, <br /> ASSIGNED TO: v` �l� EMPLOYEE M DATE: o a/I(P <br /> Date Service Completed (if already completed): SERVICE CODE: CU 1 PVI E: R7 <br /> Fee Amount: LP ��p� Amount PaidC` �o Payment Date j� .. <br /> Payment Type Invoice# Check# 1 SbS Receive)8y: <br /> i <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07!47108 <br /> ;S <br />