Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> D <br /> OWNER/OPERATOR <br /> ^ CHECK If BILLING ADDRESS <br /> FACILITY NAME ,/ , <br /> n -inoIn -pr.1m,�> <br /> SITE ADDR/E_SSc � �aG� �Z I S' <br /> 1(157 1 Street Number Direction ll Street NameFG Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP AYM, <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# ,VT <br /> AIA D PHONE#2 EXT. BOS DISTRICT 0 ATION O O' <br /> ( ) SDA <br /> CONTRACTOR/ SERVICE REQUESTOR N 71,NMENEPAT,q�7' <br /> REQUESTOR <br /> ` ► A n CHECK If BILLING ADDRESS <br /> PHO��(� �V 'C.S� r EXT. <br /> BUSINESS NAME iAN 3a� <br /> HOME or MAILING ADDRESS FAX# Nl <br /> CITY STATE ZIP 4 Gni q <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; <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/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 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 provided t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: V ( /e— <br /> COMMENTS: —ro //��� M <br /> ACCEPTED BY: 6Z is-q EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed: /Z ISERVICE CODE: �� P/E: <br /> Fee Amount: �� Amount Pai S2. 0� Payment Date ILI/-Z/ <br /> Payment Type Invoice# Check# (�3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />