Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#, <br /> OWNER/OP TOR <br /> CHECK'f BILLING ADDRESS <br /> FACILITY NAME <br /> '� o h ✓mit v� (xA 0 Yc <br /> SITE ADDRESS <br /> �G�"t�re--e /r t Number Direction / M MC h <br /> HOME Or MAR IN,j ADDRESS (If Different from Site Address) ` <br /> . J'7( ti G i" Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> SPI) 7 i-a6 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQ U STOR - -- <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS INS <br /> BUSINESS NAME l ` V PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> i ( ) <br /> ICITY 7 'G� STATE ZIP C S 12- <br /> BILLING <br /> 2BILLING ACK14OWLEDGErOEN T: 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 /> II I also certify that I have prepared this ap ication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,;�A�and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �G% / DATE: <br /> T^, <br /> PROPERTY I BUSINESS OWNER'O 1 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PART)f,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 /> t0 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. p <br /> TYPE OF SERVICE REQUESTED: T�C I � to h QP'l Pik <br /> COMMENTS: <br /> ��llavl�e G � �vJr'I � SEP'�L 6 2016 <br /> COUN <br /> SAN JVAOVIN TY <br /> ENVIHo PARTMENT <br /> HEALTH <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: L` �' / EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P IT: <br /> Fee Amount: c') Amount Paid ( 3 0 0 Payment Date <br /> Payment Type r A S Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />