Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1 1 'C� Cf �f(n1'nS� l��l�' l ! t <br /> I. <br /> OWNER/OPERATOR 1_ <br /> ���� �l 14L I i � CHECK If BILLING ADDRESS I� <br /> i l Vt� <br /> FACILITY NAME A g Jb <br /> SITE ADDRESS <br /> Ir <br /> Street arne1 m, StreetNumbar Dire ,n �Co� atn <br /> ZID Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) k(1 <br /> Creel Number lug Sheet Name <br /> CITY Y`7f7,r l <br /> STATECA ZIP <br /> HONE t r� Ems' APN# LAND USE APPLICATION# <br /> P ONE#2 C, ExT. BOS DISTRICT —A LOCATION CODE <br /> CONTRACTOR/ SERVI E REQUESTOR <br /> REQUESTOR �� CHECK if BILLING ADDRESS <br /> (�� <br /> BUSINESS NAME PHONE# ExT• I <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE zip r' <br /> I <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 <br /> or 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 clone in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standa STATE au FEDER L laws. <br /> APPLICANT'S SIGNATURE.: DATE: c`L <br /> PROPERTY/BUSINESS OWNER❑ OPERATOL 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: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> infonnation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Nevv <br /> COMMENTS: <br /> REGEIVED <br /> DEC 10 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRO <br /> ACCEPTED BY: l uL✓f o? (q EMPLOYEE#: E E� <br /> ASSIGNED TO: �' VI L^1 L' EMPLOYEE#: DATE:I <br /> Date Service Completed (if already completed): SERVICE CODE: ? I P 1 E: IL ��s <br /> Fee Amount: w Amount Paid �Sa, _-_ Payment Date l_2-f t o/1 <br /> Payment Typel,'.' Invoice# Check# M 4 g�tf.ilID g­7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 _ <br /> Q-1 <br />