Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S RVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ZA-N67- <br /> 33,211- Street Number Direction /i Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> °— <br /> PHONE#? EXT. BOS DISTRICT LOCATION CODE <br /> c Z <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HO E�orMAILING ADDRESS FAX# <br /> T 72 - lac-- 4,,1,4724e x'14�c/ c ) <br /> CITY 0 ST Ic- ZIP <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 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: 2/2 /may <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: 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 /> information 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. 1 <br /> TYPE OF SERVICE REQUESTED: Oo d ` ✓� E��� <br /> COMMENTS: RECEI L <br /> DEC 2 3 20rjc� <br /> SAN JOAQUIN COUtJT� <br /> ENVIRONVIEN ALt i, <br /> HEALTH DEPAP <br /> ACCEPTED BY. . EMPLOYEE#: DATE: / <br /> 2 23 O <br /> ASSIGNED TO: 1 i J _ /� EMPLOYEE#: 6 2/� DATE: Z 25 a <br /> Date Service Completed (if already Completed): SERVICE CODE: Z� PIE: �d <br /> Fee Amount: 3 � �� Amount Paid 3 L.f S _ Payment Date 2— 2 3 f Q <br /> Payment Type �� Invoice# Check# Received By: <br /> -- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />