Laserfiche WebLink
SAN JOAQUiry COUNTY ENVIRONMENTAL HEALTH Lir-PARTMENT <br /> SERVICE REQUEST <br /> Ty a of Business or Property FACILITY ID# SERVICE REQUEST# <br /> nPG S-Tkc /-S 7 r GDOD IGI SF00-�5q '0 <br /> OWNER/OPERATOR <br /> f � � � CHECK If BILLING ADDRESS I� <br /> C _ <br /> FACILITY NAME <br /> SITE ADDRESS —�(-+L+ w �\ (Nv <br /> I <br /> Street Number Direction Street Name _ Cit Zi i Code <br /> HOME Or'MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT• BGS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SEMgCE IU.Q ESTOR <br /> REQU TOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME J PHONE# EXT. <br /> \5-9P1LI-C MTL lam' (aQu y I C7 0 <br /> HO E or MAILING ADDRESS FAX# <br /> CITY t C oN STQT ZIP G S 2'�t <br /> EILLiNG AOKNOWLEDGEIAENT: 6, 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 /> 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 and FEDERAL laws. / <br /> APPLICANTr S SiGNAT URE:Gam- 'S DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: Whei: 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 Sameltrr}e.6t�i provided to me or <br /> my representative. y� Uri <br /> TYPE Or SERVICE REQUESTED: ()I 1 L� ���I fu� <br /> COMMENTS: � <br /> SAN dOAUUIN COUNTy <br /> HEp1-7H C)PART <br /> ACCEPTED BY: .1 'a /,,' EMPLOYEE#: DATE: <br /> ASSIGNED TO: fl�� S EMPLOYEE#: DATE: <br /> Date Service Compiev:d (if=:Iready completed): SERVICE CODE: S( o u PVI E: '!/1 <br /> Fee Amount: �r �(� Amount Paid Payment Date �C2 /c-� 44� <br /> Payment Type Invoice# Check# ;' C7 G- Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />