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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# OE C REQUEST# <br /> OWNER/ PERATOR <br /> f�1 u A CHECK If BILLING ADDRESS <br /> FACILITY NA, <br /> A ' I^ ^V` <br /> SITE ADDRESSDir n F /I }—�� ��(^ <br /> -=a'-L Street Number (`J b t Street Name' b ��Ci'�r Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) J� <br /> I Street Number • 0 L�Stree NOme" `--� <br /> CITY AE <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ' / <br /> +{1^.f3 �/' /( 12 i /1 T-•� CHECK If BILLING ADDRESS <br /> BUSINESS NAMF�V"1 � --tiI� �-5(_��#�] PHONE# �E,Xr• <br /> an <br /> HOME Or MAIADDRESS FAX# <br /> LIN CVC <br /> CITYr <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 /> I also certify that I have prepared this applicationand that th work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, TATE and FEDERAL la <br /> APPLICANT'S SIGNATURE: DATE: J- LQ <br /> PROPERTY/BUSINESS OWNERg OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tilie <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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is prov&kAe Or <br /> my representative. ••pi"'NN <br /> WI <br /> T <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: s <br /> W,"QV w C <br /> H��Ty�PAR��N <br /> N <br /> ACCEPTED BY: j EMPLOYEE#: DATE: <br /> ASSIGNED TO: kad In EMPLOYEE#: DATE: 0 <br /> Date Service Completed (if already completed): SERVICE CODE: O�j J PIE: Iwl1 <br /> Fee Amount-11 <br /> W Amount Paie Payment Date <br /> Payment Type (�7 Invoice# Check# �' 7Receiv d By: <br /> JP <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />